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BENEFITS SCHEME Application for Membership

BENEFITS SCHEME Application for Membership
Please enter your full name?
I wish to join the Benefits Scheme and authorise Central Pay Branch to deduct from my pay the monthly sum of £19.33 as determined by the Police Federation for Northern Ireland. I also understand that the sums deducted may increase from time to time and such increases will be notified to me by the Federation. Student Officer’s premiums are deferred for 1 year. (b) I nominate below the person(s) to whom I wish the benefit sum to be paid in the event of my death
I consent to the Police Federation for Northern Ireland holding and transferring my personal data for the purposes of underwriting, processing and administering my membership of the PFNI Benefits Scheme. Personal information which you supply to us will be used to underwrite, process and administer membership of the PFNI Benefits Scheme. We will also need to share this information with the scheme underwriters, Foresters Friendly Society, and PSNI to collect subscriptions from your salary. PFNI will not share information provided for this purpose with any other company or agency. For further information on how your information is used, how we maintain the security of your information, and your rights to access the information we hold on you, please see www.policefed-ni.org.uk
NOTE (i) In making payments, the trustees of the scheme shall have regard to, but are not bound by, any nominations. (ii) If the name of more than one person is given in either FIRST or SECOND beneficiary and the member wishes the benefit sum to be divided other than equally, he should indicate the proportion to be paid to each nominee. (iii) Revision of one’s beneficiaries may be made at any time by completing a new form.
Please complete this form and it is important that all questions are answered truthfully and accurately. Please disclose all relevant facts that could influence or affect the assessment and/or acceptance of the application of insurance. If you are unsure whether a particular fact is relevant, then this information should be disclosed. If a policy is issued without all relevant information being provided, the Insurer may avoid payment of a claim under the policy. If you are in doubt as to whether certain information is relevant you should disclose it. If you consider that the responses to any of the questions in the application form require any expert or third party knowledge that you do not have, please indicate this in your answer. The Insurer must be notified in writing of any changes to the details provided on the application form, including those relating to health, pastimes, travel or country of residence that occur before the policy is issued.
Please enter the person's name:


If yes, please provide full details and dates and name of insurance company




FT and Inches e.g 6FT 1 inchs
E.g. 14st or 88.9kg
(*A unit is a single pub measure of a small glass of wine, spirits or half pint of beer, lager or cider)