ICI-Nominated dependants-08:ICI death benefits - ICI Pension Fund

Nominated Dependant’s form
Important:
This form is to be completed only by you as a member of the ICI Pension
Fund. Please complete all sections of this form.
• Your nomination will be treated in the strictest confidence and
normally it will only be looked at by the Trustee in the event of
your death.
• This form does NOT entitle your Nominated Dependant to a pension.
• However, it does ensure that your Nominated Dependant will be
considered for a pension in the event of your death. A Nominated
Dependant’s pension will only be paid if, at the relevant time, they
satisfy the Trustee that they meet the conditions laid down in the Trust
Deed and Rules.
• This form cancels any earlier nomination form.
• If you change your mind as to whom you would like to receive a
dependant's benefit, you should complete a new form – please call
01707 607500 to request one. Changing your next-of-kin in your
company personnel records will not automatically change your
nomination form.
• If you have any questions regarding the completion of this form, please
call 01707 607500.
PLEASE USE BLOCK CAPITALS
Section 1 – Your details
Your full name:
Your employee/pension number:
Your marital status:
Your full address:
Section 2 – Application status (please tick the box that applies to you)
I am a member of the ICI Pension Fund, I am not married, and wish to nominate the person
specified in Section 3 to receive a dependant’s pension.
I am a Special Category member, but my spouse is dependent upon me because he/she is wholly
incapacitated, and I wish to nominate my spouse as specified in Section 3.

Section 3 – Nominee/spouse’s details
Full name:
Date of birth:
Marital status:
Relationship to you:
(For example brother, spouse, common law partner)
Your full address:
Section 4 – Data Protection Act 1998
I understand that I am providing the Trustee with personal data, and possibly sensitive personal data, within the
definition of the Data Protection Act 1998. By signing this form I also consent explicitly to the Trustee (and any other
data processors and controllers it uses) processing any personal data and any sensitive personal data about me for any
purposes associated with my application for a Nominated Dependant’s pension. This information may be transferred
to third parties who advise or assist the Trustee. Where I disclose to the Trustee personal data relating to the
Nominated Dependant or other individuals, as agent on behalf of those individuals, I:
(a)
(b)
give consent on their behalf; and
have informed them of the identity of the Trustee as the data controller in relation to their data, and the
purpose (as set out above) for which their personal data will be processed.
Member’s signature:
Date:
Print name:
Section 5 – Declaration
I declare that the information I have provided in this application is true and correct.
I understand that I, or the person I have nominated, will be required at some time in the future to provide further
information to the Trustee and/or Membership Secretary in order to support this application.
I further understand that, where this application is made for a dependant’s pension, it will be acknowledged in
writing and retained, and the decision as to whether or not a dependant’s pension will be payable can only be made
at the time of my death.
I may revoke this nomination at any time by writing to the Trustee in the form specified to me at that time.
Member’s signature:
Date:
Print name:
Please send this completed application to:
The Administrator, PO Box 545, Redhill, Surrey, RH1 1YX.