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Accident, Sickness & Hospitalisation Plan

Applicant


Applicant Details

Please note age must be between 18 and 59.

Policy


Policy Details

(please note that this could lead to a double Direct Debit collection)
without incurring a double Direct Debit collection
Your start date will be confirmed on your Schedule of Insurance which will be dispatched to you within 4 working days of receipt of this application.

Address


Payment


Third Party Declaration


Please note: This section is only to be completed if the person paying for the plan is not the policyholder.

I declare that I will pay the Direct Debit for the policy in the name of: and this level of financial commitment is affordable now and in the future.

Should a claim arise, I understand that I am not eligible to benefit in any way from the policy.

Declaration


The applicant(s) hereby apply for insurance to London General Insurance Company Limited Irish Branch (the insurer) under their usual terms and conditions. The applicant(s) confirm that the information supplied in connection with this proposal is correct to their knowledge and belief. The applicant(s) note that they should keep a record of all information supplied for the purpose of this proposal and that a copy of such information is available upon request.

The applicant(s) consent to the seeking of information from other insurers and authorise the giving of such information for such purposes. They also consent to the insurer or their agents seeking medical information from any doctor who at any time has attended them concerning anything which affects their physical or mental health and the applicant(s) authorise the giving of such information.

Warning: The current premium may increase with 30 days notice

 

 

Notice under the Data Protection Act 1988 & 2003

The applicant(s) confirm and agree that information about them and this Proposal may be retained on paper and computer by APRIL Ireland and used:

  1. by London General Insurance Company Limited Irish Branch, APRIL Ireland and other businesses that provide insurance services relating to the proposal as may be necessary for the administration of their policy and dealing with claims. In dealing with claims under their policy they agree that it may be necessary for APRIL Ireland to obtain and use sensitive personal information about them.
  2. to provide information about them (whether provided in the proposal or claim form) to other insurers for the prevention of fraud and to other third parties for the purpose of administration of their policy or any claim. Details of such third parties and other insurers will be made available on request.

The applicant(s) have been provided with details of the procedure to follow in the event of a complaint. By submitting this Proposal they agree to the Declarations above.

Their contact information may be used to send them details about other products and services available from APRIL Ireland that might interest them. If they do not wish to receive this information please tick this box.

In Progress