Voluntary Benefits Master Application Form

Please print name
Employee Number
Date of Birth

IMPORTANT NOTES:

  • Please ensure that this form is completed either within the enrolment window, usually November to December, at an appropriate Lifestyle event, or when you first join CORETX.
  • Once completed please return this form to .
  • Any benefits you select below within the enrolment window will have an annual start date of
    1 January. Cover elected at any other time (e.g. as a new employee or following a Lifestyle event) will be effective from the first day of the month following your election.
  • By completing and returning this form you are requesting the benefits and levels as outlined below. Please select ALL of the voluntary insurance benefits that you require on this form.
  • If you apply for a benefit then you will be required to keep this benefit for the 12 month period starting from the 1 January renewal date, or up until the next enrolment window if selected during the year. You will not be able to cancel any of these voluntary benefits mid-year unless you leave the company or you experience a permitted Lifestyle event.
  • Please calculate the premium applicable based on the premium rates provided on the portal. Your calculations will be checked and verified by HR/our advisers. You will receive an email confirming your selections within three days of receipt of the completed form.

For staff with existing benefits during an enrolment window

  • If you do not return this form then your existing benefits will continue at the existing levels. That is, any benefits you have previously selected will remain covered at the same level.
  • If you submit this form, but leave any benefits you currently takebelow blank, they will be assumed to be no longer required by you and will not be renewed.
  • This form will replace any previously completed forms

I would like to elect the following benefits from the voluntary benefit options:

Benefit / Employee Statement / Monthly Premium
Critical illness (you) / Cover amount required: £______
Must be in multiples of £25,000 and cannot exceed £500,000 or five times your salary / £______
(per month)
Critical illness (your partner) / Cover amount required: £______
Must be in multiples of £25,000 and cannot exceed the employee’s cover. Maximum limit is £200,000 / £______
(per month)
Top-up group life insurance / Cover of ___ times salary required (in addition to the cover already provided by my employer)
Maximum of 10 times salary, including the core cover provided by CORETX / £______
(per month)
Dental insurance / Cover level required: Level ___ (Core, 1, 2, 3 or 4)
Cover required for (please tick one)
Cover for / Please tick
Employee only
Employee and partner
Employee and family
Employee and children
Cover can be selected for the core level or levels 1 to 4 / £______
(per month)
Benefit / Employee Statement / Monthly Premium
Health Assessment / Cover can be selected for you and, if required, your partner.
Cover level required (please tick one):
Cover for you
Assessment type / Please tick
360+ Health Assessment
360 Health Assessment
Lifestyle Health Assessment
Female Health Assessment
Mammography*
Cover for your partner
Assessment type / Please tick
360+ Health Assessment
360 Health Assessment
Lifestyle Health Assessment
Female Health Assessment
Mammography*
* The mammography can only be selected with certain other assessments. See details on the Portal. / £______
(per month)

IMPORTANT: All cover will be subject to the insurers’ terms and conditions. Please ensure that you have read all of the necessary documentation before selecting your benefits.Cover elected as part of the annual enrolment period will be effective from the next 1 January.Cover elected at any other time (e.g. as a new employee or following a lifestyle event) will be effective from the first day of the month following your election.

Signed
Date