PENSIONS
SUPPLEMENTARY GROUP AVC SCHEME
APPLICATION
Please tick ( ) as appropriate.
1. Employee information
Name of Scheme:
Name of Hospital/
Local Authority:
Union/Association:
Title:
Mr
Mrs
Ms
Other
Employee’s Name:
Home Address:
Employee Contact Number:
D
D
M
M
Y
Y
Y
Y
Date of Birth:
Normal Pension Age:
D
D
M
M
Y
Y
Y
D
Y
Date of Joining Service:
D
M
M
Y
Y
Y
Y
Date Employee is to be included in Plan:
Occupation:
Officer/Non-Officer Grade:
P.P.S. Number:
€
Salary (per annum):
Personal public service no.
D
Marital Status:
D
M
M
Y
Y
Y
Y
Spouse’s Date of Birth:
Is this Employee entitled to any other retirement benefits under this or
previous employment or under any Retirement Annuity Contract?
Yes
No
If Yes, please provide details:
Name of Scheme
€
Amount of Benefit
Insurance Company
Revenue Reference
2. Contribution details
Employee’s Regular Additional Voluntary Contributions (AVC):
€
per annum
%
OR
Employee’s Special Single Contribution:
of Salary
€
3. Investment details
IRIS
Pension Managed Fund
%
%
Pension Evergreen Fund
%
Others
(please nominate)
%
Contributions will be invested in IRIS unless stated otherwise.
Page 1 of 4
4. Employee’s declaration and data protection consent
1. I apply for membership of the Supplementary Group AVC Scheme established to receive additional voluntary contributions
and agree to be bound by the Rules of the Supplementary Group AVC Scheme. I authorise deductions from my earnings
in respect of any contributions required from me under the Rules of the Supplementary Group AVC Scheme.
2. I authorise New Ireland to obtain information and benefit details from the trustee/administrator (and/or any relevant
Life Office) of any Scheme, arrangement or contract of which I am or have been a member.
3. I declare that the statements in this application including any statements written at my request are true and complete.
“Company” means New Ireland Assurance Company plc.
“New Ireland Group” means the Company and any subsidiary or associated companies.
“Information” means any information including medical and non-medical given by me or on my behalf in connection with
this application or any further information which may be given at a later stage either in writing, by email, at a meeting or
over the telephone.
“Marketing” means direct marketing and cross-selling of the services and/or products provided by the Company and/or
any company within the New Ireland Group or arranged by the New Ireland Group with a third party.
I understand and consent that the Company and its duly authorised agents may hold and use the Information on
computer file, in any other dematerialised form or in written hard copy on its own behalf and on behalf of other
companies within the New Ireland Group and may use or pass the Information to any company within the New Ireland
Group or third parties for administration, regulatory, customer care and service purposes.
I understand that in the event of my application not proceeding, information provided in connection with my application
will be retained by New Ireland for a period of six years to facilitate any future application by me and as a protection
against non-disclosure of material facts.
I agree that the Company or a duly authorised agent of the Company may contact me in person,
by phone, or by letter if it considers that my financial planning arrangements need to be reviewed
or my level of cover needs to be revised.
I agree that the Information may be held and used by the Company for Marketing purposes.
Yes
No
Yes
No
I understand that I may write and advise the Company to cease to hold and use the Information for Marketing purposes
at any time.
Signature of Employee:
D
D
M
M
Y
Y
Y
Y
Date Signed:
5. Office use only
Name:
District Number:
Agency Number:
New Ireland Assurance Company plc.,
11-12 Dawson Street, Dublin 2.
T: (01) 617 2000 F: (01) 617 2800.
E: info@newireland.ie W: www.newireland.ie
A Member of Bank of Ireland Group.
New Ireland Assurance Company plc is regulated by the Financial Regulator.
300117
V5/09/07
Page 2 of 4
6. Contribution details
Name of Employer:
Supplementary Group AVC Scheme
Please deduct from the remuneration payable to me and remit to New Ireland Assurance Company plc
the instalments of premium shown below and any amended instalments in lieu thereof under the terms
of my policy as New Ireland Assurance Company plc may notify to you from time to time. I recognise that
such deductions, being made solely for my convenience, may be terminated by you at any time. I also
recognise that beyond remitting deductions made to New Ireland Assurance Company plc you may have
no responsibility of any kind in the matter.
Signed:
D
D
M
M
Y
Y
Y
Y
Date:
Employee
Details
Employment
Details
Name in full as registered with employer
Location/Group No.
Staff/Army/Works No.
Office/Station/Depot/District
Occupation/Rank
Department Section
Payroll
Details
Office from
which paid
Office
Use Only
Policy No.
Amount of
Periodical Deduction
Important Notes for
Scheme Officer:
How
Paid
€
Weekly
Fortnightly
Half-monthly
Scheme No.
Frequency
First Deduction
Date
Total Quarterly
Deduction
4-weekly
monthly
1. The deduction referred to is in addition to deductions for any existing policies.
2. If for any reason you are unable to implement this deduction, please return this authorisation to New Ireland stating the reason.
Page 3 of 4
New Ireland Assurance Company plc.,
11-12 Dawson Street, Dublin 2.
T: (01) 617 2000 F: (01) 617 2800.
E: info@newireland.ie W: www.newireland.ie
A Member of Bank of Ireland Group.
New Ireland Assurance Company plc is regulated by the Financial Regulator.
300117
V5/09/07
Page 4 of 4