I wish to opt-in/avail of the Member Death Benefit Insurance Programme as provided for Capital Credit Union, and arranged by CUNA Mutual Group Services (Ireland) Ltd.
Signature:                                          Date:                                             

• I am a member of Capital Credit Union and am eligible to join the Member Death Benefit Insurance Programme
• I have read and understood the Key Facts and Programme Summary as provided to me
• I will undertake to have sufficient funds in my share account to pay for the annual Premium attaching to the provision of this insurance cover and my inclusion in the Programme
• I understand that this is a Programme that will auto-renew on an annual basis, and the attaching premium will be deducted from my share account on this basis
• I am also aware that the benefits and cost of this Programme may be varied annually but I will be informed of any such changes or updates through the Credit Union’s AGM Booklet and from the Credit Union’s website - www.capitalcu.ie
• I understand that this Programme is due to commence on 01/01 and that I will pay for 12 months cover to 31/12. Should I Wish to opt-out or cancel my participation in the Member Death Benefit Insurance Programme, I will inform the Credit Union in writing of my decision
• My understanding is that my participation in the Programme will automatically stop should I cease to be a member of Capital Credit Union or if there are insufficient funds in my account to cover the annual cost of my premium
• • I understand that the insurer can opt to terminate the Programme and cover at the end of each Programme period

I wish to confirm that the information I have provided to Capital Credit Union is correct and I provide my consent to this information being shared with CUNA Mutual and its insurers, for the purposes of my membership of the Member Death Benefit Insurance Programme, as outlined in the Key Facts & Programme Summary sheet – MDBI 08.17