Payroll Deduction AVC Life Cover Plan Change Request Form

Payroll Deduction AVC 

Life Cover Plan Change Request Form 

Pensions 

Please complete in BLOCK CAPITALS and tick (3) where appropriate 

1. Employee information (for employees of civil service, public sector, state related agencies, HSE and Voluntary Hospitals). 

Existing Plan No.: 

Name of Scheme: 

Name of Employer: 

First Name: 

Surname: 

Home Address: 

Phone No.: 

Marital Status: 

Occupation: 

Salary (per annum): 

Date of Birth: 

D D M M Y Y Y Y 

2. Life Cover 

(If you wish to amend your AVC Pension Contribution in addition to adding a Life Cover Premium then please also complete Section 4. 

Otherwise your Life Cover Premium will be payable in addition to your current AVC Pension Contribution) 

Life Cover Benefit: _ (Minimum cover is €20,000. Maximum cover is €100,000. Please note Revenue Rules set out 

the maximum Lump Sum available to you in the event of death) 

Age next birthday (Maximum age 60 next birthday) Sex: Male Female Smoker: Yes No 

Life Cover Premium: _ (Please see Rate card for calculation of weekly Life Cover Premium) 

Important notes about your Life Cover Benefit: 

• Life Cover ceases on reaching the earlier of your Normal Retirement Age and age 65. 

• You must pay your Life Cover Premium as it falls due and continue to actively contribute to your AVC pension plan in order for your Life 

Cover Benefit to remain in force. 

• If you have chosen indexation to apply to your AVC pension contributions then your Life Cover Benefit and Life Cover Premium will also 

increase with indexation in line with your AVC pension contributions each year. 

• The weekly Life Cover Premium as set out above is payable in addition to your AVC Pension Contribution and will be deducted at the 

same frequency as your AVC Pension Contribution. This premium is used to provide you with your chosen level of Life Cover and will not 

purchase units in your AVC pension plan. 

3. Health and other details 

You are legally obliged to inform us of all relevant information (material facts) in the application process. Material facts are those, which 

an insurer would regard as likely to influence the assessment and acceptance of a proposal for insurance. If you are in doubt as to 

whether certain facts are material, such facts should be disclosed. 

The policy may be cancelled, any claim on the policy may not be paid and you may have difficulty purchasing insurance elsewhere: 

• If you do not inform us of all material facts 

• If any of the information you provide is not true and complete 

• If you do not inform us of any changes in your medical and/or other information which occur before the policy start date 

It is your responsibility to ensure that the information provided is true and complete whether the information was completed by you or on 

your behalf. All material facts in relation to the person to be covered must be provided by that person and not the policy owner. 

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3. Health and other details (continued) 

If you proceed with the application, the resulting policy will be based on the information provided: 

• as set out on this form containing your application details, 

• as set out in any other form related to your application, 

• as set out in any communication from you notifying us of any changes required in advance of the policy start date, and 

• as set out in any questionnaire completed by you or by a medical examiner and signed by you. 

You may submit answers to any medical questions, if you have not already done so, direct to the Chief Medical Officer, New Ireland 

Assurance, 11-12 Dawson Street, Dublin 2. 

Please indicate in your letter your name and the application number to which the information applies. All information will be treated in 

strictest confidence. 

We may not necessarily contact your doctor(s). Even if we do, you must still disclose all material facts. We may ask you to have a medical 

examination with a nurse or a doctor. 

Any changes to the information provided in the application process which occur before the policy start date must be notified immediately 

in writing to New Ireland Assurance. 

Material Facts Exemption in Relation to Genetic Tests 

You are not required to disclose any genetic tests you may have had and we will not have any regard to any genetic tests, which may come 

into our possession. You are however required to provide us with full details (other than genetic tests) in answer to all the health and 

lifestyle questions including full medical details about your family history. 

Please answer the following questions. 

1. Within the last 10 years have you had medical advice for any of the following illnesses, or been referred 

for tests or investigation for any of these conditions; 

• Stroke, heart valve surgery, heart attack, angina, angioplasty, heart by-pass, cardiomyopathy or any other disease 

or disorder of the heart or blood vessels? 

• Alzheimer’s Disease, Parkinson’s Disease, Motor Neurone Disease or any other disease or disorder of or injury 

to the brain? 

• Any form of cancer including Leukaemia or Lymphoma? 

• Diabetes or kidney disease or disorder (other than kidney stones)? 

• HIV infection, Hepatitis B or C or any other disease or disorder of the liver? 

• Drug abuse or alcohol abuse where reduction has been recommended by a medical advisor? 

• Multiple sclerosis or any other neurological disease or disorder? 

• Ulcerative colitis, Crohn’s disease, blood clotting disorder or haemophilia? 

• Schizophrenia, bipolar affective disorder, manic depression, psychosis, paranoia or mania, or any other mental 

health conditions for which you have been hospitalised? 

• Any lung disease or disorder (other than asthma) which has required oral steroids or hospital admission? 

Yes 

No 

If you have answered yes to any of the above questions then for each condition disclosed please give details of a) exact nature of condition 

b) date of diagnosis c) treatment received d) date of last symptoms e) if you have made a full recovery? 

2. Are you currently awaiting any medical referral, medical investigation, test results 

or surgical procedure not disclosed above? Y: N: 

If you have answered yes to the above question please give details of a) reason b) appointment date c) nature and severity of any 

current symptoms 

3. Have you ever had an application for life cover on your life declined, postponed 

or accepted at an increased premium? Y: N: 

If you have answered yes to the above question please give details of a) date b) reason for this c) name of insurance company 

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3. Health and other details (continued) 

4. Have you smoked cigarettes, cigars or pipe tobacco in the last 12 months? Y: N: 

5. What is your height and weight? ft ins st lbs 

6. Please provide the name and address of your doctor. (If none please write “None”) 

4. AVC Pension Top-up only 

(Only complete this section if you wish to amend your AVC pension contribution. The Life Cover Premium should be inserted in Section 2). 

Date increase to take effect from: 


01 

(No need to be completed if the increase is to take effect from the next possible date) 

I wish to increase the regular AVC Pension Contribution to this policy by the following: By _ per 

Any top-up to your regular AVC Pension Contributions will be invested in the same fund(s) as your current regular AVC Pension 

Contributions. 

5. Employee’s declaration and application 

1. I agree to be bound by the rules of the scheme and authorise deductions from my earnings in respect of any contributions or premiums 

required from me under the rules of the scheme. 

2. I have read through all the replies to the questions in this application and I declare that the statements in this application including any 

statements written at my request are true and complete and shall be the basis of the proposed contract. 

3. I understand that I must be actively at work in order to be entitled to apply for Life Cover and that if I cease payment of my Life Cover 

Premium or my AVC Pension Contributions my Life Cover Benefit will cease with immediate effect. 

4. I agree to New Ireland seeking information from any doctor who has attended me and from any insurance company to which an 

application for insurance of any kind on my life or health has been made and I authorise them to give New Ireland such information. I 

agree that this authority will remain in force after my death. 

5. I have read and understand the notes in relation to material facts and understand that if I do not tell you all material facts this contract 

could be void. 

6. I understand that in certain circumstances the Life Cover Benefit paid in the event of death may have to be restricted to ensure that 

Revenue limits are not exceeded. 

7. I understand that the Life Cover Benefit is subject to underwriting and acceptance by New Ireland Assurance Company plc and that I am 

only on cover for the Life Cover Benefit from the date of notification of acceptance. 

@ 

Signature of 

Employee: 

Date 

Signed: 


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New Ireland Assurance Company plc., 

11-12 Dawson Street, Dublin 2. 

T: (01) 617 2000 F: (01) 617 2075. 

E: info@newireland.ie W: www.newireland.ie 

New Ireland Assurance Company plc is regulated by the Central Bank of Ireland. A member of Bank of Ireland Group. 

301453 V3.05.12 

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Payroll Deduction AVC Life Cover Plan Change Request Form

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