Connaught Region Insurance
This short form goes to Insurance convenor, who will contact you regarding Group Insurance.
GDPR rules. By completing and submitting this form, you give us permission to send you details regarding the Group Insurance Scheme.
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Group Name *
Group Address *
Please supply address, include Eircode (if you can). Group number would also be beneficial. 
Your name *
Your Mobile number *
Your Email address
Group email address is best. Your personal email address will also direct Certificate to you. 
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