Beneficiaries:

Case studies
Who qualifies
Apply for help

Donating:

Individuals
Companies
Local Institutes
Table of donations
Request details
Corporate video

About us:

Who we are
News
Annual report
Accessibility
Privacy policy
Downloads
Contact details

Home Page

Insurance Charities Day 2008

Application

To request help from The Insurance Charities please use the below form, alternatively you can download this form and send by post or fax it to us.

Subject:	Potential Beneficiary Form
	General information:
Title:
First Name(s):		*Required
Surname:		*Required
Date of Birth:		*Required
Address: (including Postcode)		*Required
Telehone Number:	Daytime:	*Required
	Evening:	*Required
Email Address:
Marital status:
	Dependant details:
	Spouse:
Name:
Date of birth:
	Children:
Child 1:	Name:
	Date of birth:
Child 2:	Name:
	Date of birth:
Child 3:	Name:
	Date of birth:
Child 4:	Name:
	Date of birth:
Child 5:	Name:
	Date of birth:
	Please give the full name of the person on whose insurance service this application is based:

	Details of insurance service:
Employer:
Employer address:
Dates of service:
Employee/pensioner reference number:
Brief details on why this application is being made:

Downloads:

	Membership application form
	Gift Aid form (UK Individual)
	Potential Beneficiary form
	Promotional material
	Our latest newsletter