Premium Registration

Thankyou, Please update your personal details:

Your Date of Birth *

Your Address

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Post Code

Email Address *

Home Number

Mobile Number

Beneficiaries

PLEASE NOTE you must provide details of all current beneficiaries even if they have been previously notified.

1st Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

2nd Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

3rd Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

4th Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

5th Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

6th Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

Partners information

Partner first Name

Partner last Name

Partner Date of Birth *

Partner Beneficiaries

Your spouse partner should nominate the beneficiaries for their life insurance. As with the member nomination, this can be split between a number of people but you must state what percentage each will received in the event of the death of your partner.

(YOU SHOULD NOT COMPLETE THIS ON BEHALF OF YOUR PARTNER)

PLEASE NOTE you must provide details of all current beneficiaries even if they have been previously notified.

1st Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

2nd Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

3rd Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

4th Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

5th Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equalequal

6th Beneficiary Name

Relationship
…Partner/SpouseSonDaughterBrotherSisterMotherFatherGrandmotherGrandfatherGranddaughterGrandsonCousinFriendOther

Percentage
…0%5%10%15%20%25%30%35%40%45%50%55%60%65%70%75%80%85%90%95%100%equal

WHEN YOU CLICK TO SEND THIS FORM YOU CONFIRM THAT DETAILS ARE CORRECT AND THAT THE INFORMATION CONTAINED IN THIS SECTION REFLECT THE WISHES OF YOUR SPOUSE PARTNER