Death of a PB BEFORE April 2008 December 2013 | Page 17

Beneficiary’s Form
(Preserved Benefit Member)
Please complete this form in BLOCK CAPITALS using BLACK INK
l

Enter details of deceased member in Section 1 l Sign and date Sections 5, 6 and 9 where appropriate

l

Complete sections relevant to the benefits being claimed

SECTION 1

Details of Deceased Member

National Insurance Number
Surname Forename(s)
Date of Death

SECTION 2

Title

Former Employer

Spouse’s/Civil Partner’s/Nominated Cohabiting Partner’s Personal Details

Surname

Forename(s)

Title

Home Address
Post Code

Home Tel. No.

Mobile Tel. No.

Email Address
National Insurance Number

SECTION 3

Date of Birth

Method of Payment for Spouse’s/Civil Partner’s/Nominated Cohabiting Partner’s Pension

(please choose ONE method and complete any necessary details in CAPITALS. Please consult your bank or building society in case of difficulty).

(A)
Direct to my Bank Account
Name of Bank
Address of Bank
Bank Sort Code

Bank Account No.

Name(s) of Account Holder(s)
(B)
Direct to my Building Society Account
Name of Society
Address of Society
Society Sort Code

Society Bank Account No.

Society Account No.

Name(s) of Account Holder(s)

SECTION 4

Health Scheme Contributions

(Please complete only if you are an EXISTING member of Westfield and wish to contribute by deduction from pension).

SECTION 5

*Weekly or Monthly amount £

Declaration

I have read the ‘Guide to LGPS Benefits on the Death of a Preserved Beneficiary’ and declare that I have
completed Sections 1, 2, 3, 4 and 8* on this form correctly to the best of my knowledge and belief.
Signed

Date

* Delete whichever does not apply

Continues overleaf >>

Form 7C
March 2013