form test - URC Pensions

United Reformed Church
Group Life Assurance Scheme

A lump sum benefit is paid if you were to die while in active service of the URC. The trustees will decide who to pay your benefit to. When they decide they will consider your circumstances at the time of your death, and your wishes recorded on this form.

Please fill in this form to tell the trustees who you would like to receive your benefit.

If you want to update your Nomination Form, please fill in a new form as the latest dated one takes priority.

About You

Full Name

First

Middle

Last

Date of Birth

Your National Insurance Number

Who would you like the Trustees to consider payment to?

Beneficiary 1

Title

(Mr/Mrs/Miss/Other)

Name

First

Middle

Last

Relationship to me (if any)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth

Percentage of any payment due

If you want the benefit to be paid to more than 1 person please complete further boxes and ensure the percentage adds up to 100%

Do you want to add a second beneficiary?

Yes
No

Beneficiary 2

Title (beneficiary 2)

(Mr/Mrs/Miss/Other)

Name (beneficiary 2)

First

Middle

Last

of (beneficiary Relationship

Relationship to me (if any) (beneficiary 2)

Address (beneficiary 2)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth (beneficiary 2)

Percentage of any payment due (beneficiary 2)

Do you want to add a third beneficiary

Yes
No

Beneficiary 3

Title (beneficiary 3)

(Mr/Mrs/Miss/Other)

Name (beneficiary 3)

First

Middle

Last

Relationship to me (if any) (beneficiary 3)

Address (beneficiary 3)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth (beneficiary 3)

Percentage of any payment due (beneficiary 3)

Do you want to add a fourth beneficiary

Yes
No

Beneficiary 4

Title (beneficiary 4)

(Mr/Mrs/Miss/Other)

Name (beneficiary 4)

First

Middle

Last

Relationship to me (if any) (beneficiary 4)

Address (beneficiary 4)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth (beneficiary 4)

Percentage of any payment due (beneficiary 4)

Do you want to add a fifth beneficiary

Yes
No

Beneficiary 5

Title (beneficiary 5)

(Mr/Mrs/Miss/Other)

Name (beneficiary 5)

First

Middle

Last

Relationship to me (if any) (beneficiary 5)

Address (beneficiary 5)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth (beneficiary 5)

Percentage of any payment due (beneficiary 5)

Your confirmation

I understand the Trustees are not bound by my wishes but I would like the Trustees to consider them.

Electronic Signature

By typing your name above, you are providing an electronic signature and agree that it is the legally binding equivalent of your handwritten signature.

Date

United Reformed Church Group Life Assurance Scheme

About You

Who would you like the Trustees to consider payment to?

Beneficiary 1

Beneficiary 2

Beneficiary 3

Beneficiary 4

Beneficiary 5

Your confirmation

I understand the Trustees are not bound by my wishes but I would like the Trustees to consider them.

United Reformed Church
Group Life Assurance Scheme