WMP Benevolent Fund & Medical Scheme
Application Form
 Either print off this form and complete by hand, or enter details into form and then print off prior to signing then forward to the address on the bottom of the form.
 Click ? if you require an explanation. 

Please fill in the following

Part 1
How to join
 
Authority for deductions and nominations of beneficiaries
WMP Benevolent Fund
I hereby authorise the Police Authority, until further notice to make deductions from my pay at the appropriate rate on behalf of the WMP Benevolent Fund and nominate the under-mentioned person or persons to receive the benefits payable on my death under the Scheme and in the case of a nominee under the age of eighteen years. I hereunder nominate a responsible adult capable of advising such nominee in the best use of such benefits.

    Membership No.

   

Full Name:   Full Name of nominee:
      

  ?
Address:      
    Proportion of benefits
   

?
Post Code:      
        Full name of advising adult/or relationship
Phone:  

?
          
Date of Birth:   Signature  
Police Force:  

Date of Joining service:   Date:

     
  

 

 

 

 

 

 

 

 

  

Part 2
  Children Under 18   
   

Date of Birth:

Please fill in the following
  1. Full Name:
       
I wish to join/update the Private Medical Scheme   Date of Birth:
The following persons are to be covered.
(Please complete as applicable)		   2. Full Name:
         
      Date of Birth:
Member          
Date of Birth:		  

3. Full Name:
Full Name:      
       Date of Birth:
Spouse/Partner 
Date of Birth:		   4. Full Name
Full Name:      
         
I hereby authorise the Police Authority, until further notice to make deductions from my pay at the appropriate rate for the Private Medical Scheme. I understand that all benefits will be paid in accordance with the Benevolent Fund Rules and that no member shall be entitled to claim for any medical condition which exists during the five years prior to joining. I further understand that such conditions will be covered when i have completed 24 month’s continuous membership and have gone for one year without medical attention for the condition.
 
Signature Date:

WMP Benevolent Fund & Medical Scheme, Guardians House, 2111 Coventry Road, Sheldon,
Birmingham B26 3EA Phone: 0121 700 1100 Fax: 0121 700 1111
 

Easy payments

Subscriptions are collected direct from you by the Police Authority, or Direct Debit Mandate members outside West Midland Police Authority. 
This is the safest and best way, because, as it is automatic, you never lose cover through accidentally missing a payment.

The payroll Deduction Authority is provided at the foot of the Application for you to complete. It can, of course, be cancelled at any time and your cover will cease from the date your cancellation becomes effective.

The dependents of members aged over 18 who were previously covered by the scheme should phone the Benevolent Fund Office for a  Debit Mandate so that subscription can be collected from their Bank or Building Society account.


Back to the top

 

Nominee
The nominee is the benificiary of the £2000 death grant from the Benevolent Fund Benefits.

Proportion of Benefits
The proportion of benefits, the member can leave the grant to more than one person.
e.g. 50% to wife and 50% to children etc.

Advising Adult
Advising adult is if the death grant is left to a child of the member under 16 years.


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