MEMBERSHIP FORM 1. MEMBER 2. SPOUSE/PARTNER I wish to

MEMBERSHIP FORM
1. MEMBER
I wish to join the Society and I agree to be bound by the Rules:
Do you have Current Health Insurance AVIVA, GLO, LAYA, VHI ,OTHER ?
Yes
No
If YES please enclose documentation showing the plan & level of cover for Inpatient & Outpatient care so we can
decide if any “waiting periods” will apply to any enhanced or additional cover benefits provided by the Society.
Prison Officer No: ____________ Prison:_____________ Date of Joining Service________
Name: _____________________________ D.O.B: ___________ Contact No: ____________
Address:____________________________________________________________________
PPS Number: _______________________E-mail Address:___________________________
2. SPOUSE/PARTNER
I wish to put my Spouse/Partner on cover with the Society:
Does your Spouse/Partner have current Health Insurance AVIVA, GLO, LAYA, VHI ,OTHER ?
Yes
No
If YES please enclose documentation showing the plan & level of cover for Inpatient & Outpatient care so we can
decide if any “waiting periods” will apply to any enhanced or additional cover benefits provided by the Society.
Full Name of Spouse/Partner: __________________________ Date of Birth:____________
If Married Date of Marriage: ________________________ PPS Number: _______________
3. I wish to put the following Child/Children on cover with the Society:
Does your Child/Children have current Health Insurance AVIVA, GLO, LAYA, VHI ,OTHER ?
Yes
No
If YES please enclose documentation showing the plan & level of cover for Inpatient & Outpatient care so we can
decide if any “waiting periods” will apply to any enhanced or additional cover benefits provided by the Society.
Details of Children to be included in cover:
Name
Date of Birth
______________________________ _____________________
______________________________ _____________________
______________________________ _____________________
PPS NUMBER
_____________________
_____________________
____________________
PLEASE TURN OVER TO SIGN &COMPLETE FORM---
__________________________________________________________________
Initial Waiting Periods: An initial waiting period during which no benefit will be payable will apply to all new entrants who are not
currently insured as follows – NEW MEMBER -26 Weeks except where new officer within the service -13 weeks, Maternity Cover
-52 Weeks . New Born – Once Registered & Premium paid.
Pre Existing Condition Waiting Period- Where no current medical insurance cover exists and the signs or symptoms of any
medical condition, illness or ailment existed at any-time in the 6 months prior to applying for insurance a “waiting period” of 5
years will apply. A 2 year waiting period for Enhanced In-Patient Care will apply to a member for pre-existing illnesses where
the member had a previous health insurance contract with another provider.
Please complete in full and sign and date below
Name of Bank:
_________________________
Bank Address
_________________________________________________
Branch
_________________________
BIC CODE _______________________
IBAN Number______________________
Other information required
Please supply the following
1. Birth Certificates for all those seeking Insurance.
2. Copy of Marriage Certificate / Civil Partnership or Completed Delaration
in respect of Partner.
3. Letter of Confirmation from previous Insurer confirming level of cover .
4. Signed Deduction Authorisation Form.
I WISH TO JOIN/ADD MY SPOUSE/PARTNER/DEPENDANT(S)(AS OVERLEAF)TO THE
PRISON OFFICERS MEDICAL AID SOCIETY AND I AGREE TO HAVE THE APPROPRAITE
DEDUCTIONS MADE FROM MY SALARY.
I AGREE TO BE BOUND BY THE RULES OF THE SOCIETY .
Signature: ____________________ Reg No: _____________ Date: ____________
The Rules of the Society provide for serious penalties should any information given here
be found to be incorrect
POMAS OFFICE USE
DFD:
_________________
Date of Cover
_________________
Deferred Waiting Period if any
_________________
Age Loading if over 34 years of age
_________________
Input by
_________________
Authorised by
_________________
Prison Officers Medical Aid Society
397E N.C. Road Dublin 7 DO7 TAC9 Tel 01 8308963 E-mail [email protected] Website www.pomas.ie