We are committed to maintaining the personal data that you provide in accordance with the requirements of the Republic of
Ireland’s Data Protection Act 1988 & 2003. The privacy statement below gives further information about this.
For the purposes of the Data Protection Act 1988 & 2003, the data controllers in respect of any personal information provided
is Assurant General Insurance Limited. You may be assured that we will treat all personal data as confidential and will not use or
process it other than for legitimate purposes. Steps will be taken to ensure that the information is accurate, kept up to date and
not kept for longer than is necessary. Measures will also be taken to safeguard against unauthorised or unlawful processing and
accidental loss or destruction or damage to the data.
The personal information that you provide us will be used for a number of different purposes including: to manage and administer
your policy; to assess your application or subsequent claim(s) including: conducting credit checks; to offer you insurance products
and services (except where you have asked us not to do so) and to help us develop new ones; to contact you with details of
changes to the products you have bought; for internal analysis and research; to comply with legal or regulatory requirements;
and to identify you when you contact us. We may use external third parties to process your personal information on our behalf in
accordance with these purposes, subject to their strict compliance with the Data Protection Acts.
Unless you have asked us not to do so, your personal information provided may be shared with other related organisations and
our agents, so you can receive, either in writing or by telephone, details of other products and services which may be of interest
to you; and in order for us to comply with any legal or regulatory requirements. We may share your personal information with our
related companies for the purposes set out in this Privacy Statement.
To the extent that you provide sensitive personal data, we (and our related companies) may also process such sensitive personal
data, both manually and by electronic means, for the same purposes described in this Privacy Statement. Sensitive personal data
includes information as to your physical or mental health or condition; or the commission or alleged commission of any offence
We may transfer your personal information to countries located outside the European Economic Area (the EEA). This may happen
when our servers, suppliers and/or service providers are based outside of the EEA. The data protection laws and other laws of
these countries may not be as comprehensive as those that apply within the EEA – in these instances we will take steps to ensure
that your privacy rights are respected. Details of the countries relevant to you will be provided to you upon request.
You have the right to ask for a copy of the information that we hold about you. There may be a charge for this. If any of the
information that we hold about you is incorrect, please write to us at Assurant General Insurance Limited and Assurant Life
Limited c/o Assurant Services Ireland Limited, PO Box 781, South City Delivery Office, Cork, and we will make any amendments
I consent to the information (including any sensitive personal data) on this form and on any claim form being used and disclosed
as set out. I understand that I have the right to access, update and rectify any of my personal data by writing to Assurant General
Insurance Limited and Assurant Life Limited c/o Assurant Services Ireland Limited, PO Box 781, South City Delivery Office, Cork.
Exclusive to IBA members Exclusive to IBA members
D D M M Y Y Y Y
If you do not wish to receive information about other If you do wish to receive information about other products
products and services through the post or telephone, and services via EMAIL or SMS, please tick the appropriate
please tick this box: box. Email: SMS:
OFFICE USE ONLY
Broker Mortgage Start Date
D D M M Y Y Y Y
UK member companies: Assurant Group Limited (registered in England no. 3264846); Assurant General Insurance Limited (registered in England no. 2341082),
authorized and regulated by the Financial Services Authority; Assurant Life Limited (registered in England no. 3264844), authorised and regulated by the This insurance is underwritten by Assurant Solutions, the trading name of Assurant General Insurance
Financial Services Authority; Assurant Services (UK) Limited (registered in England no. 2515130); Assurant Intermediary Limited (registered in England no.
Limited and Assurant Life Limited who are authorised and regulated by the Financial Services Authority. Mortgage Payment Protection Insurance
4019801), authorised and regulated by the Financial Services Authority; Adminicle Limited (registered in England no. 4176842), authorised and regulated by the
Financial Services Authority. The registered office of all UK member companies is 117-119 Whitby Road, Slough SL1 3DR. Their registered address is 117-119 Whitby Road, Slough, Berkshire, SL1 3DR, England.
Now that you have found your dream home, the next step is to make sure it is
adequately protected. That’s why we offer My Broker Mortgage Payment Protection
Insurance, a policy designed to protect your mortgage repayments in the event you Exclusive to IBA members
are unable to work due to accident, sickness or involuntary unemployment.
Mortgage Payment Protection Insurance
And we have options that allow you to further protect your repayment in the event
you are hospitalised or diagnosed with a critical illness. Personal Information
Title (Mr, Mrs, Miss, Ms, Other) Address
How it works
My Broker Mortgage Payment Protection Insurance allows you to select the cover
you need, how much (depending on your mortgage repayment) and the length of
time you need it for. Then if you are unable to work, typically for 30 consecutive Surname
days (for Accident, Sickness or Involuntary Unemployment), your monthly mortgage Contact Telephone No. (including area code)
repayment will be paid until you return to work (for the selected period of cover). The Gender
sections below provide further details on how to select the cover that’s right for you. E-mail Address
Date of Birth
D D M M Y Y Y Y
Cover Amount Benefits
Monthly Mortgage Repayment 1. Select the standard cover required
Step 1 Step 2 Step 3 € Accident & Sickness
Additional cover Involuntary Unemployment only
€ Accident, Sickness & Involuntary Unemployment
Choose the Benefits How long do you Decide on the cover Eligibility Total cover required 2. If you have selected Accident & Sickness cover,
want cover for? amount you need To be eligible for cover you must be (at the start date): € choose any additional cover required
• At least 18 and under 64 years of age
The first step is to decide the If the basic cover you have The next decision is how long you Now that you know what cover Critical Illness Hospitalisation
• Actively working for at least 6 months
cover that suits you best. selected includes Accident & need benefits to be paid for. suits you best, you need to The maximum cover amount allowed is 110% of
• A permanent resident of the Republic of Ireland Benefit Period please select the benefit required
There are three basic options Sickness benefits you then have decide on the monthly benefit your mortgage repayment, 75% of your net monthly
If you have opted for Accident & • Have a mortgage agreement in force on your
to choose from: the option to add some extras: amount. Typically, this will be your income, or €2,000, whichever is the lesser. for Accident & Sickness 12 month 24 month
Sickness cover, you can select main residence
monthly mortgage repayment • N
ot aware of any impending disability or
• Accident & Sickness • Critical Illness benefit a benefit period of 12 or 24
amount. You also have the option involuntary unemployment
Covers your mortgage If you choose to add Critical months. If you have also opted Existing Cover
to cover an additional 10% on top
repayment if you are unable illness cover to your policy, for Hospitalisation cover, the
of this to protect other mortgage
to work due to Accident or an amount equal to 24 times same benefit period will apply as
related costs such as your life or Cost Are you currently covered on a payment protection policy? Yes No
Sickness. your monthly benefit will be selected for Accident
home insurance premiums. The cost of cover is dependent on the benefits you have Do you wish to transfer from this payment protection policy? Yes No
paid to you in one lump sum & Sickness.
• nvoluntary Unemployment
I The maximum benefit amount selected, the benefit period and the amount of cover you
on the diagnosis of a critical Only a 12 month benefit period need. The cost can be as little as €2.76 for every €100 If Yes, has the existing cover been in place for at least 6 months? Yes No
Covers your mortgage illness. The illnesses covered allowable is 110% of your
is provided on Involuntary of cover!
repayment if you are unable are listed in the Terms mortgage repayment, 75% of Customer Declaration
to work due to Involuntary and Conditions, which are your net monthly income, or Speak to your financial advisor who can provide a quotation 1. I declare that I have read and understood the contents of this proposal and have been advised to read the terms and
Unemployment available upon request. €2,000, whichever is the lesser. tailored to your needs. conditions to ensure I understand them fully.
ccident, Sickness & 2. I am a named party on a mortgage agreement.
• Hospitalisation cover
Involuntary Unemployment Exclusions 3. I am resident in the Republic of Ireland and am in employment or self employed, of at least 18 hours per week
Hospitalisation cover pays a continuously for the past 6 months.
Covers your mortgage monthly benefit to you in the Some exclusions will apply to My Broker Mortgage Payment
4. I understand that the start date of this insurance is the date the mortgage is completed and this insurance is subject to
repayment if you are unable event you are hospitalised. Protection Insurance depending on the cover you have Assurant Solutions receiving the appropriate premium.
to work due to Accident, The benefit is payable after selected. Your financial advisor can provide you with a
5. I declare that I am currently in good health and not aware of any impending incapacity, hospitalisation or involuntary
Sickness or Involuntary three days’ hospitalisation. summary of cover which highlights the main exclusions unemployment.
Unemployment. on the policy. In addition, the Terms and Conditions are 6. I declare to the best of my knowledge and belief that the information contained in this proposal is true and accurate and
available upon request and provide details on all exclusions. this proposal shall form the basis of an agreement between myself and Assurant General Insurance Limited.
INSTRUCTION TO YOUR BANK TO PAY DIRECT DEBITS
Originators Identification No. (OIN) 304729 Originators Reference: Assurant General Ins Ltd
Please complete parts 1 to 4 to instruct your Bank to make payments directly from your account.
Then return the form to:- Assurant General Insurance Limited, c/o Assurant Services Ireland Limited,
Cork Business & Technology Park, Model Farm Road, Cork.
1. Please write the name & full address of your 3. Sort Code
bank & branch - -
4. Your instructions to the Bank, and your Signature
instruct you to pay Direct Debits from my account at the request
2. Name of account holder of Assurant General Insurance Limited.
n confirm that the amounts to be debited are variable and may be
debited on various dates.
n shall duly notify the Bank in writing if I wish to cancel this
instruction. I shall also so notify Assurant General Insurance
Limited of such cancellation.
The Direct Debit Guarantee
his is a guarantee provided by your own Bank as a member n Y
ou can cancel the Direct Debit Instruction in good time by writing
of the Direct Debit Scheme, in which Banks and Originators of to your Bank.
Direct Debits participate.
n If you authorise payment by Direct Debit, then Signature(s)
n Your Direct Debit Originator will notify you in advance of
the amounts to be debited to your account
n Your Bank will accept and pay such debits, provided
that your account has sufficient available funds.
n f it is established that an unauthorised Direct Debit was
charged to your account, you are guaranteed a prompt refund
by your Bank of the amount so charged. D D M M Y Y Y Y