Please check this box if you would prefer for an emailed personalised application / payment form or posted forms to read, sign and return
Full name of applicant inc title (Mr, Mrs, Miss)
Address
Postcode
DoB DD/MM/YYYY
Amount you wish to save £
Frequency Weekly (£2.30 - £5.75) Monthly (£10 - £25)
Number of years (minimum 10)
method of payment Payroll (where available) Standing order
Benefit per week £35 £70 £105
I wish to pay Weekly Monthly
Benefit is payable for 12 weeks please indicatie if you prefer a different period 6 weeks 26 weeks
Add Hospitalisation benefit £7 £21 £35