Wmfs group life scheme application form effective from 01 11 18

West Midlands Fire Service Sports and Welfare Fund Group life scheme application form Full name (member)

Full name (spouse)

DOB :

DOB:

*Level of Cover :

Level of Cover :

* Select from table on page 2

I / we wish to join the WMFS Group Life Assurance Scheme and hereby authorise the West Midlands Fire Service Payroll Section to make the deduction from my pay for myself / and my partner. I am a subscribing member of the WMFS Sports & Welfare Fund.

I confirm that I have taken reasonable care to ensure that the statements given are honest and correct. I understand that if they are not correct this could result in the insurance being treated as though it never existed or a claim being rejected.

Signature:

Date:

Important: If you divorce, remarry or change your partner you must inform the Treasurer of the WMFS Sports & Welfare Fund in writing. Failure to do this may result in loss of benefits.

Please complete in BLOCK CAPITALS: Name:

Brigade No/Pension No:

Home Address:

Post Code:

HomeTel. No:

Work Tele. No:

FOR OFFICE USE ONLY: Total deduction: ÂŁ S&W Membership checked:

Payroll Month: Certificate sent out: Deduction checked on:

/

/

By:

George Burrows is a trading name of Arthur J Gallagher Insurance Brokers Limited, which is authorised and regulated by the Financial Conduct Authority. Registered Office: Spectrum Building, 7th Floor, 55 Blythswood Street, Glasgow, G2 7AT. Registered in Scotland. Company Number: SC108909 www.ajginternational.com 1 GB1106/V2

West Midlands Fire Service Sports and Welfare Fund Group Life scheme (Including Best Doctors®, GP Care on Demand, Legal Expenses and Motor Breakdown) Category: Serving member Partner Serving member Partner Retired member under age 60 Partner Retired member aged 60-64 Partner Retired member aged 65-69 Partner

Benefit level Monthly premium £100,000 £21.92 £100,000 £17.91 £150,000 £30.11 £150,000 £26.10 £40,000 £18.64 £40,000 £14.62 £20,000 £18.64 £20,000 £14.62 £7,500 £18.64 £7,500 £14.62

Premiums payable are determined by the age of WMFS member

Important information: 

Membership of the scheme is open to all members of WMFS Sports & Welfare Fund, and their partners.



Membership can continue into retirement providing you have been subscribing to the scheme for at least six months prior to the date of retirement. This also applies to partners.



Entry to the scheme for both member and partner is subject to the satisfactory completion of a Health Declaration form.



All cover ceases at age 70. Partners can remain in the scheme until they reach the age of 70 years or until the serving or retired member reaches age 70, whichever occurs first.



Partner cover will cease on the withdrawal or death of the serving/retired member.

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If you divorce, remarry, change partner or move you must notify Membership Services in writing; failure to do this may result in loss of benefits to your nominated beneficiary.



If you change your partner they will not be covered under the scheme unless a new application has been accepted.

Completed application, beneficiary nomination and Health Declaration forms must be returned to: Membership Services WMFS Sports & Welfare Fund Fire Service Headquarters 99 Vauxhall Road Birmingham B7 4HW The Life Assurance policy is issued by Risk Assurance Management Limited on behalf of Lloyds Underwriters under the Binding Authority Contract No. B0775RCB07718.

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West Midlands Fire Service Sports and Welfare Fund Group Life scheme Beneficiary nomination form (serving / retired member) Name: Brigade No/Pension No: All lump sum benefits arising under this Scheme, on the death of a member, will be paid to such of his/her beneficiaries as the Trustees of the Scheme decide, in accordance with the powers contained in the Rules. A member may, however, express a wish as to who should benefit although this will in no way be binding. If you should like to instruct the Trustees please complete the details below: To The Trustees: It is my wish that any benefits, arising under the scheme, should, in the event of my death, be paid in the proportions and to the person(s) indicated below;

Beneficiary 1 Name Address Relationship Proportion of Benefit %

Beneficiary 2 Name Address Relationship Proportion of Benefit %

Beneficiary 3 Name Address Relationship Proportion of Benefit %

Signature Date

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West Midlands Fire Service Sports and Welfare Fund Group Life scheme Beneficiary nomination form (partner) Name: Name of Member : All lump sum benefits arising under this Scheme, on the death of a member, will be paid to such of his/her beneficiaries as the Trustees of the Scheme decide, in accordance with the powers contained in the Rules. A member may, however, express a wish as to who should benefit although this will in no way be binding. If you should like to instruct the Trustees please complete the details below: To The Trustees: It is my wish that any benefits, arising under the scheme, should, in the event of my death, be paid in the proportions and to the person(s) indicated below;

Beneficiary 1 Name Address Relationship Proportion of Benefit %

Beneficiary 2 Name Address Relationship Proportion of Benefit %

Beneficiary 3 Name Address Relationship Data Privacy Notice

Proportion of Benefit %

George Burrows is a trading name of Arthur J. Gallagher Insurance Brokers Limited (Gallagher).

We are the data controller of any personal data you provide to us. We collect and process personal data in order to offer and provide insurance services and policies and to process claims. Personal data is also used for business purposes such as fraud prevention and detection, financial management, to generate risk modelling, conduct analytics including to advise, improve and develop our products and services and to comply with our legal and regulatory obligations. This may involve sharing information with, and obtaining information from, our group companies and third parties such as (re)insurers, other brokers, loss adjusters, credit reference agencies, service providers, professional advisors, our regulators or fraud prevention agencies. We may record telephone calls to help us to monitor and improve the service we provide as well as for regulatory purposes.

Signature Date

Please see our Privacy Notice for further information on how your personal data is used, shared, disclosed and retained, your rights in relation to your personal data and how to contact our Data Protection Officer. Our Privacy Notice can be found at https://www.ajg.com/uk/ brokerage-privacy-policy/. From time to time we may make important updates to our Privacy Notice and these may in turn affect the way we use and handle your data. Please ensure you review our Privacy Notice periodically to ensure you are aware of any changes.

GB1106/V2

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If you are providing us with personal data of another individual that would be covered under the insurance policy we may be placing or services we may provide to you, you shall ensure that you have obtained all appropriate consents, where required, tell them you are providing their information to us and show them a copy of this notice. You must not share personal data with us that is not necessary for us to offer, provide or administer our services to you.