IAS ADULT - OPEN TO NEW MEMBERSHIP - JOIN US NOW!

Authorised by the Prudential Regulation Authority and regulated by the

Financial Conduct Authority and the Prudential Regulation Authority

The account that pays you money when you're too ill to work.

I apply to become a member under the terms of the INDIVIDUAL ACCOUNT SYSTEM of THE GRAND UNITED ORDER OF ODDFELLOWS FRIENDLY SOCIETY

Forenames:

Surname:

Email Address:

Date of Birth:

Lodge:

No.

Place:

Full address:

Postcode:

Martial Status:

National Insurance Number:

Are you already a member of this or any other friendly society?

If yes, please provide the name of the lodge/society and the amount of annual contribution/premium in respect to life:

I would like to join the following:

How did you hear about our Society/Products?

Tick:

Online

Press

Friend

Other (specify below)

Specify:

HOW WILL WE USE YOUR DATA

The information that you provide on this form will be held by the Grand United Order of Oddfellows and used to set up and administer the policy for which you are applying and for other business purposes. By taking out this policy we will rely upon this as our standard client agreement and for your own benefit and protection, you should read the terms within the Financial Products Key Information Document and Financial Products Table that are available to be reviewed on this page before signing. If you do not understand any point, please ask for further information. I confirm that I have not been given any advice by the Grand United Order of Oddfellows in relation to the purchase of this plan.

DECLARATION

Please confirm:

I declare the statements, whether in my own handwriting or written on my behalf are true and complete. I also declare that I am currently in good health and not receiving any treatment for any medical condition for which treatment is ongoing and could be considered terminal. No material facts or circumstances regarding myself have been concealed . I confirm that I will be resident in the United Kingdom when contributions are paid. (NB – An Individual is regarded as a resident if absences from the United Kingdom are only of a temporary nature (e.g. for business or pleasure) and for tax purposes the United Kingdom comprises England, Scotland, Wales and Northern Ireland. A copy of the terms of membership will be made available on request along with a copy of this application form). I declare that I do not have any other Tax Exempt Plans ( excluding ISA’s) with this or any other Friendly Society which would exceed my maximum Tax Exempt Allowance for Tax Exempt Savings Plans of £25 per month or £270 per annum. Furthermore, I declare that, the total of my contributions to this and other taxable qualifying policies does not exceed £3600 per annum.

Date:

Failure to mention any material fact (this is a fact that an insurer would regard as likely to influence the assesment and acceptance of an application for a policy) may affect the amount payable upon death or maturity. If an applicant is in any doubt whether the fact is material or not, it should be disclosed anyway.

Processing of your personal data is necessary for the performance of our contract for services with you. Generally, this is the lawful basis on which we intend to rely for the processing of your data. Our policy is to gather and process only that personal data which is necessary for us to conduct our services appropriately with you.

Conditions and copies of the completed application forms are available on request.but if required please print your application before submission

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