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Personal Accident Plan

Applicants

Policy Holder

To be eligible you must be aged between 18 and 65 inclusive.

Partner

Required
Required
Required
Required
Required

Children

Title Forename Surname Date of Birth
Required Required Required

Cover Details

Monthly
(please note that this could lead to a double Direct Debit collection)
without incurring a double Direct Debit collection
(depending on date chosen, this could lead to 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. The start date cannot be a date in the past. The start date cannot be more than 30 days in advance.

Address

It is mandatory for the applicant to fill in at least one phone number.

We will email all policy documentation to the broker. By providing your customer’s email address above, we will also send documentation directly to your customer to save you time.

Payment

You must select who is paying for the policy to continue.

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.

You must enter your relationship to the policy holder.

Payment

Payment by Irish bank account only.

Declaration

If you are the customer’s adviser you have your customer’s authority to accept the declaration below on their behalf.

I confirm i have read and accept the following

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DISCOUNT FUEL CARD

As a Hive member, you’re also eligible to apply for a Discount Fuel Card provided by DCI, Ireland’s leading fuel management provider. The card gives you an exclusive discount on every litre of fuel you purchase at participating stations plus a host of amazing benefits. Tick this box to consent to us acting as an introducer and passing your contact details to DCI, who will provide you with more details.


Please help us to go green

Each year we send policyholders an annual review letter and an Insurance Product Information Document, which is a summary of key information relating to your plan. As an environmentally responsible company, we would like to ask for your permission to send you this information by email - not only will this reduce the amount of paper we use, it will also make it easier for you to manage your policy paperwork.

Please can you tick the box below to confirm you are happy to receive this correspondence by email. Sincere thanks for your support in helping us to make a difference to the environment.

I request that my annual reviews and Insurance Product Information Documents are sent to me by email:

In Progress