Please complete and return this form to: Avon & Somerset Police Federation Office, 1 St David’s Court, Windmill Road, Clevedon, North Somerset BS21 6UP. (Once completed you will need to print this form and sign it)

Group Insurance Scheme (ASGIS)Officer Application Form

Surname: Forename(s):

:rebmun ecroF:htrib fo etaD

Address:

Applicable to new recruits and serving officersBy signing this application form, you confirm that you are a subscribing member of the Police Federation and have not been absent from your employer's service on account of ill-health or injury at any time during the eight weeks preceding this application.Applicable to new recruits onlyMembership of the scheme is free for the first 52 weeks of service and at £15.39* per month from weeks 53 to 104. Following this the full premium of £25.41* will be deducted from your salary each month.

The maintaining of an up-to-date will is advised. Payments are made by the Trustees under the terms of the ‘Trust Deed’, which would normally be to the member’s chosen beneficiary. The Trustees will, at their own discretion, agree payment in the event of a life claim. I understand that in all matters, in accordance with the Trust Deed, the decision of the Trustees is final.

Beneficiary details

Address:

Surname: Forename(s):

I am a: new recruit serving officer Date of joining Avon & Somerset Police Force:

Signed: Date:

£25.41* per month inclusive of the Federation’s administration fee of £0.91p and Insurance Premium Tax

*The premium payable will be subject to periodic review and may go up or down.

Cover is conditional to continued membership of the scheme and ceases at age 70. Some benefitsreduce or cease on retirement from the police service and the life benefit reduces again at age 65. Pleasecontact the Police Federation or George Burrows for further information. Cover ceases immediately ontransfer to another force, resignation or dismissal.

I wish to join the Group Insurance scheme

I would like to join the scheme with effect from:

I hereby authorise the deduction of the monthly premium from my pay in respect of my membership of the above scheme.

It is important that you notify the Federation immediately of changes to personal or beneficiary details.

Payroll number: National Insurance no:

Email:

Relationship to member:

It is important that the information you have provided to us is to the best of your knowledge true, accurate and complete and reflects your current circumstances. If your circumstances change, please inform us. If we or the insurer discover that the details provided to us are untrue, inaccurate or incomplete, this may result in refusal of a claim and/or your policy being cancelled or treated as if it never existed.

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

GB1001/LMG270416/V2

Group Insurance Scheme Partner Application Form (Late Joiner)

Surname:

Address:

Beneficiary details

‘Partner’ means the person to whom the member of the associated policy is married or in a Civil Partnership with or, if not, a person who is openly co-habiting with him or her and who has been so cohabiting for the six months’ period prior to the date of their inclusionin the policy, and on whom such a member is financially interdependent.This section is to be completed by the Partner

I hereby apply to join the scheme with effect from:

Signed: Date:

I declare that I am in good health and:1. During the last 12 months, I have not attended or been advised to attend a hospital or clinic (excludes routine visits to a GP),

for any form of advice, test, investigation or operation (excluding consultations for colds,asthma, influenza or pregnancy).2. I am not currently receiving any treatment, medication or medical attention, either regularly or irregularly for any medical

(includes diabetes), physical or psychiatric condition, or awaiting any medical or surgical consultation, test or investigation.(Excludes tablets, medicine or drugs taken for asthma, colds, influenza, routine vaccinations, or contraception).

3. I have never been tested positive for HIV/AIDS, or Hepatitis B or C, nor am I awaiting the result of such a test. I have nottested positive for any sexually transmitted infection in the last 5 years, nor am I awaiting the result of such a test.

4. No application to an Insurance Company for life, accident or sickness insurance, or critical illness cover has ever beendeclined, postponed, offered or accepted with special terms or restrictions, or been withdrawn for any medical reasonor hazardous pursuits.

5. I share a joint financial commitment with the employee/member of the scheme and understand that if I am admitted toscheme membership; my membership is dependent on continuity of cover by the employee/member.

I confirm that I have taken reasonable care to ensure that the statements above 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.

Forename(s):

Date of birth:

Surname: Forename(s):

Address:

Surname: Forename(s):

Station/division: Payroll number:

I hereby authorise the deduction of the sum of £6.46*, inclusive of the Federation's administration fee of £0.80p and Insurance Premium Tax (IPT) from my pay, in respect of my partner’s membership of the Group Insurance scheme.

Signed: Date:

*The premium payable will be subject to periodic review and may go up or down.

Partners can remain in the scheme until they reach the age of 70 years or until the serving officer reaches 70 years, whichever occurs first. Benefit levels depend on the age of the subscribing officer. Please refer to the Federation or George Burrows for further information. Cover is conditional to the serving officer's membership.

This section is to be completed b y the New Recruit/Serving Officer Please return this form to the Police Federation Office: 1 St David’s Court, Windmill Road, Clevedon, North Somerset BS21 6UP

Email:

National Insurance No: Email:

(Once completed you will need to print this form and sign it)

GB1003/LMG270416/V2

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

Group Life, Critical Illness, Travel, Personal Accident& Sickness Benefit Scheme

Officers Name: …………………………………………………………………………………………..

Collar No. : ………………………………………………………………………………………………...

Marital status: ……………………………………

Name of Next of Kin: (state relationship, ie spouse) ……………………………………………….

Next of Kin D.O.B ………..……………………………

Next of Kin Address: (if different) …………………………………………………….……………...

……………………………………………………………………………………………………………..

Dependants: (include name and date of birth) ………………………………………………….……

…………………………………………………………………………………………….……………….

……………………………………………………………………………………………………………..

Officer Beneficiary Details: (in the event of your death who do you wish to receive the benefit i.e. spouse,children etc):

…………………………………………………………………………………………….……………….

…………………………………………………………………………………………….……………….

Signature: ……………………………………………… Date: …………………………………

If you have spouse cover please ask your spouse to complete the below.

Spouse Beneficiary Details: (in the event of your death who do you wish to receive the benefit i.e. spouse,children etc):

…………………………………………………………………………………………….……………….

…………………………………………………………………………………………….……………….

Signature: ……………………………………………… Date: …………………………………

THE ABOVE INFORMATION IS IMPORTANT

PLEASE ENSURE THAT THIS FORM IS RETURNED AS SOON AS POSSIBLE TO:THE POLICE FEDERATION OFFICE1 St David’s Court, Windmill Road

Kenn, ClevedonBS21 6UP

AVON & SOMERSETCONSTABULARYTRAVEL INSURANCE SCHEMEREGISTRATION FORM – Serving Officers

Mr/Mrs/Miss/Ms Surname……………………………First Names………..………………

Address……………………………………………………………..…..….………………….

………………………………………………………….… Postcode………………….…..

Tel. No…………….…………………… E-mail address….…….……….……………….…

Date of Birth………………………….. Date of Joining……….……………………….…..

Pay Number………………………….. Collar No..……………….……………………

Name of Partner…………………………………. Date of Birth………………….……….

Child (1)…………………………………………… Date of Birth……………….….………

Child (2)…………………………………………… Date of Birth………………..…………

Child (3)…………………………………………… Date of Birth…………………..………

Child (4)…………………………………………… Date of Birth…………………..………

IMPORTANT

Signed……………………………………………….. Date………………………

When completed, please return to:Police Federation Office

1 St David’s CourtWindmill Road

KennClevedonBS21 6UP

To register with us as an insured person under the scheme, please complete thedetails below and return this form to us at the address shown. A copy of all the documents relating to the scheme are available to download from our website at http://www.avsomfed.org/services.html

As a member of the Avon and Somerset Group Insurance Scheme, you haveautomatic cover for ‘family’ travel Insurance (includes member, spouse/partner and any unmarried children under the age of 22 who reside with you and are in full time education), on a worldwide basis.

I certify that I am a member of the Avon and Somerset Group Insurance scheme and thatpremiums are deducted from my salary. I understand that if I am not a member of the Avon andSomerset Group Insurance scheme, or if my contributions stop for any reason, no travel insurance isprovided. I understand that any information about those insured, which may include sensitive data(medical history, criminal convictions), will be processed by the insurer and/or claims adjuster and/orGeorge Burrows in compliance with the Data Protection Act 1998, and only for the purposes ofproviding insurance cover, administering scheme membership and handling any claims. This maynecessitate providing data to third parties. We may use e-mail, telephone, post or other means to dothis.