Test form 3

Claim Death Benefits

This form should be filled in when a member dies, to give the trustees information about the member and their personal circumstances. The trustees may use this information to decide who any benefits from the pension scheme should be paid to and in what proportions. If there is a will or letters of administration, copies of these will help the trustees to make their decision. If there is no qualifying beneficiary, any payments we make to the member’s estate contribute to the total used for inheritance tax purposes.

"*" indicates required fields

Main Contact

If you are the person dealing with the member’s estate, please give us your contact details. This should be the person who is dealing with the member’s affairs who we can contact if we have questions about reclaiming over payments.

Name*

Title First Last

Main Phone Number*

Mobile Phone Number

Email*

Enter Email Confirm Email

Company (if this applies)

Address*

Address Line 1 Address Line 2 City County / State / Region ZIP / Postal Code

Relationship to Member*

(For example – solicitor, husband or wife)

Did the Deceased leave a Will*

Yes ( Please upload a copy)

Copy of Will

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Has a Death Certificate been issued yet?*

Yes ( Please upload a copy)

Death Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

If the member was already receiving a pension from the pension scheme, we may have already sent payment for the latest instalment. You will need to repay this amount to the pension scheme. If this applies, we will write to you after we have received the claim form and will confirm the amount that must be returned.

Details about the Deceased

Name*

Title First Last

Name of Pension Scheme*

Member Reference*

Date of Birth*

Date of Death*

Address at time of their death*

Address Line 1 Address Line 2 City County / State / Region ZIP / Postal Code

Length of time at this address

Years*

Months*

Is this a Residential Care Home

Yes

Death Overseas

You only need to fill in the section below if the death happened overseas. Please make sure that you send a copy of the death certificate along with an official translation. If not, the claim could be delayed or rejected.

Date of Departure from the UK

Intended Date of Return to the UK

Purpose of Visit

Funeral Arrangements

Husband, wife or civil partner

The member’s estate

Other

Who paid the funeral costs

Marital and Residential Status

Marital Status
If the member was either married or in a civil partnership at the time of their death, the surviving spouse or civil partner must provide copies of their marriage or civil partnership certificate, their birth certificate and their passport (photo page) and Driving Licence (photocard). If the member has previously been married, please provide a copy of the decree absolute.

Marital Status

Single

Widowed

Divorced

Separated

Married

Civil Partnership

Living with Someone

Date of Marriage or Civil Partnership

If possible, please upload a copy of the Marriage or Civil Partnership Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

If possible, please upload a copy of the surviving Husband's, Wife's or Civil Partner's Birth Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

If possible, please upload a copy of the surviving Husband's, Wife's or Civil Partner's Passport (photo page) and Driving licence (photocard)

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Has the member been married previously?

Yes

N/A

If possible upload a copy of the decree absolute

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Residential Status

The trustees will take into consideration the member’s residential status at their time of death. This is important for any member who died whilst not legally married, in a civil partnership or who has been co-habiting and sharing joint financial responsibilities for residential costs.

Was the member permanently living with anyone, other than their Legal Spouse, when they died?*

No (skip to “husband’s, wife’s or civil partner’s details”)

Yes

Name of Cohabitee

Title First Last

Relationship to Member

(for example: partner’s, son, daughter or sister)

How long have they been living together?

Years

Months

Are both parties joint names on a Mortgage or Rental Agreement?

Yes (please supply a copy of the agreement showing both names)

Mortgage Rental Agreement

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Which of the following bills did both parties share joint responsibility for?

Gas

Electric

Water

Phone

Car/ Travel

None of these

Do both parties have a joint Bank or Building Society account

Yes (please supply a copy of a bank or building society statement showing both names)

Bank / Building Society Details

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Is this person named as a beneficiary in the member's will?

Yes

Husband's, Wife's or Civil Partner's Details

If the member was married or in a civil partnership at their time of death, it is possible that we will pay a spouse’s pension. To work out and confirm this benefit, please fill in the following section. This should include details of the bank account where we should pay any benefits.

Name

Title First Last

Date of Birth

Home Phone Number

Mobile Phone Number

Address

Address Line 1 Address Line 2 City County / State / Region ZIP / Postal Code

National Insurance Number

Bank Name

(For example – HSBC)

Bank Address

Address Line 1 Address Line 2 City County / State / Region ZIP / Postal Code

Account Name

Account Number

Sort Code

Overseas Bank Accounts

Only fill in this section if you want benefits to be paid to an overseas bank account. There are special conditions which apply to paying overseas pensions. Please contact us for details of terms and charges.

Country

Local Currency

Bank SWIFT, BIC or ID

IBAN (EEA only)

Account Number

Bank Address

Address Line 1 Address Line 2 City County / State / Region ZIP / Postal Code

Other Dependents

Please provide details of all dependants and all children from the member’s current and any previous relationships whatever their age. Please ensure that this includes all children under the age of 18 and children between the age of 18 and 25 in full-time education. Please also supply details of any person, other than husband, wife, civil partner and children, who were financially supported in some way by the member who has died. If necessary additional details should be provided on the ‘Further information’ page. For the trustees to fully assess financial dependency, you must provide evidence along with the claim form. This should include copies of utility bills, joint bank or building society account information and joint mortgage or rental agreements. We may reject a claim which does not include suitable, current supporting evidence.

Please confirm number of Dependents

Dependent 1

Name

Title First Last

Date of Birth

Sex

Male

Female

Relationship to member who has died

Address

Address Line 1 ZIP / Postal Code

Please upload a copy of their Birth Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Is this person financially dependent on the member

Yes

Is this person resident at the same address as the member

Yes

Dependent 2

Name

Title First Last

Date of Birth

Sex

Male

Female

Relationship to member who has died

Address

Address Line 1 ZIP / Postal Code

Please upload a copy of their Birth Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Is this person financially dependent on the member

Yes

Is this person resident at the same address as the member

Yes

Dependent 3

Name

Title First Last

Date of Birth

Sex

Male

Female

Relationship to member who has died

Address

Address Line 1 ZIP / Postal Code

Please upload a copy of their Birth Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Is this person financially dependent on the member

Yes

Is this person resident at the same address as the member

Yes

Dependent 4

Name

Title First Last

Date of Birth

Sex

Male

Female

Relationship to member who has died

Address

Address Line 1 ZIP / Postal Code

Please upload a copy of their Birth Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Is this person financially dependent on the member

Yes

Is this person resident at the same address as the member

Yes

Dependent 5

Name

Title First Last

Date of Birth

Sex

Male

Female

Relationship to member who has died

Address

Address Line 1 ZIP / Postal Code

Please upload a copy of their Birth Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Is this person financially dependent on the member

Yes

Is this person resident at the same address as the member

Yes

Dependent 6

Name

Title First Last

Date of Birth

Sex

Male

Female

Relationship to member who has died

Address

Address Line 1 ZIP / Postal Code

Please upload a copy of their Birth Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Is this person financially dependent on the member

Yes

Is this person resident at the same address as the member

Yes

Dependent 7

Name

Title First Last

Date of Birth

Sex

Male

Female

Relationship to member who has died

Address

Address Line 1 ZIP / Postal Code

Please upload a copy of their Birth Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Is this person financially dependent on the member

Yes

Is this person resident at the same address as the member

Yes

Dependent 8

Name

Title First Last

Date of Birth

Sex

Male

Female

Relationship to member who has died

Address

Address Line 1 ZIP / Postal Code

Please upload a copy of their Birth Certificate

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Is this person financially dependent on the member

Yes

Is this person resident at the same address as the member

Yes

Further Information

The trustees can decide who receives benefits from the scheme and will take all of the member’s personal circumstances into consideration before anything is paid. You can provide details of any other information, that is not already covered in this form, about the member’s personal circumstances at their time of death that might be relevant.

Any other relevant information

Important information

Tax
Inheritance tax: The payment of lump sum death benefits on most pension schemes is ‘discretionary’ and therefore will not be part of the member’s estate for inheritance tax purposes.
Discretionary means that the trustees are free to decide who to pay the death benefit to. The trustees will often take into account the member’s wishes, although they do not legally have to follow them. This is why it is important for the trustees to understand as much as possible about the member’s personal circumstances at their time of death.
Income tax: Any pensions paid directly from the scheme to beneficiaries will be subject to income tax (PAYE) that will be deducted at source. Pension payments are not subject to National Insurance deductions.

Important information
Isio and the Trustees of your pension scheme take privacy very seriously.
Information use: We use the personal information from this form and any other information that you give us to: value your pension, maintain records for the purpose of payment of pensions, pension related payments, pension communication, market research and to analyse statistics.
Information sharing: We will release information disclosed on this form to other companies within the Isio group of companies (and any future owners), the trustee’s professional advisers, insurance companies (where requested by the trustees of your pension scheme or you), other service providers who hold or process your data on our behalf and third parties to whom we are required to transfer data by law or regulatory requirements (e.g. government and regulatory authorities).
Fraud prevention: We will check the details provided on this form with fraud prevention agencies. If you give false or inaccurate information and we identify fraud, we will pass your details to fraud prevention agencies. Law-enforcement agencies may access and use this information. We and other organisations may also access and use this information to prevent fraud and money laundering, for example, when processing a claim to pay benefits.
You can view our Privacy Notice here: Privacy Policy
Please contact us if you would like to view the Privacy Notice specific to your pension scheme.

Identity verification: Before we pay any benefits we will verify the address and identity of any beneficiary using an electronic identity checking service. Using a range of UK public registers and credit agency reports, we will automatically verify the identity of the beneficiary.
This process will leave a search footprint on the beneficiary’s credit history record but will not affect their credit rating. All checks we perform will be logged as ‘ID check’ and these have no impact on credit ratings. If the beneficiary does not meet the minimum requirements of the identity check, we will write to them to obtain further documents and information in order to verify their identity.
These measures are designed to protect the pension scheme and its members from fraudulent claims.

Declaration*

By submitting this form, you agree to our terms and conditions

I confirm that the information in this form is accurate and, as far as I know, shows the personal circumstances relating to the member at the time of their death. Please remember that it is a serious offence to make false statements, the penalties are severe and could lead to prosecution.

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