Mandate Forms Please choose a payment methodHow do you want pay?(Required) by Direct Debit by Salary Deduction Client Code or Reference(Required)Email Address(Required) Mobile NumberWhat cover is this mandate for?(Required) Life/Illness House/Motor/Accident Other There is a 4.5% charge for non-life policy's paid by DD/SDComplete the Salary Deduction MandateI hereby declare that the policy, in respect of which these deductions are being made, is being effected by me and I recognise that, beyond making and remitting deductions as specified above, my employer accepts no further responsibility of any kind in this matter. I hereby authorise my employer to deduct from my salary, the contributions plus future increases in respect of the policy as set out above and to have these deductions remitted to Halligan Insurances. I recognise that these deductions will be made solely for my convenience and may be discontinued by you at any time. I also recognise that the ultimate responsibility for ensuring the deductions have in fact been made rests with me.N.B. Where deductions fail to commence or thereafter cease the balance of premium for any related insurance will become payable immediately in order to ensure continuation of cover.Employee's Name(Required) First Last How are you Paid?(Required) Weekly Fortnightly Monthly When are you nexted paid?(Required) DD slash MM slash YYYY Employee's Date of Birth(Required) DD slash MM slash YYYY Staff Number(Required)Office Address(Required)Complete the Direct Debit MandateBy signing this mandate form, you authorise (a) Halligan Insurances to send instructions to your bank to debit your account and (b) your bank to debit your account in accordance with the instruction from Halligan Insurances. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank.Creditor’s Details: Halligan Life & Pensions Ltd - Creditor’s ID No: IE95SDD303969 William Norton House, North Circular Road, Dublin 1. Ireland.Account Holder's Name(Required) First Last IBAN(Required)BIC(Required)This field is hidden when viewing the formSignature SectionAccount Holder's SignatureElectronic Signature Agreement(Required) I understand and agree that my electronic signature is legally binding.(Required)DATA PROTECTION AGREEMENTWe comply with the provisions contained in the Data Protection Acts 1988 to 2018. We are committed to protecting and respecting your privacy. All calls, both inbound and outbound, may be recorded or monitored for quality, training and verification purposes. Data collected to bind your policy is passed by secure email in encrypted form within the meaning of the Consumer Act and GDPR, you have the right to request a copy of your details we hold on file and to change any inaccuracies or to cancel same unless we are legitimately obliged to retain same. If any doubt arises, contact info@halligan.ieAccept the Data Protection Statement(Required) I confirm that I have read and accept the Data Protection Statement(Required)
01 879 7100 
01 879 7100