Group Insurance Scheme – Online Nominee Form

Group Insurance Scheme — Online Nominee Form

Use this form to nominate who should receive your group insurance benefit. You may name up to four nominees; the proportions should total 100%. This nomination supersedes any previous nomination held on file.

Full Name

Collar Number

Status

Confirm Your Email

Post Code

Please nominate who should receive your group insurance benefit. Proportions should total 100%.

Nominee 1

Full Name

Relationship

Financially dependant upon me

Date of Birth

Address

Postcode

Proportion of benefit (%)

Nominee 2

Full Name

Relationship

Financially dependant upon me

Date of Birth

Address

Postcode

Proportion of benefit (%)

Nominee 3

Full Name

Relationship

Financially dependant upon me

Date of Birth

Address

Postcode

Proportion of benefit (%)

Nominee 4

Full Name

Relationship

Financially dependant upon me

Date of Birth

Address

Postcode

Proportion of benefit (%)

Type your full name to sign this nomination

I confirm these nominations and understand they supersede any previous nomination.