Group Membership Application - Gravesham Friendly

Completing this form will not result in you receiving additional marketing information from us.

Group scheme name This could be the group or company name.

Business type Describe the type of business you operate (e.g., retail, consulting, manufacturing).

Registered business address

Postcode

Address (line 1)

Address (line 2)

Town/city

County

Telephone number

Email address

Scheme administrator

Title (required)

First name(s)

Surname

Mobile phone number

Group policy member 1

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

Group policy member 2

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

Add another policy member

Group policy member 3

Remove

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

Add another policy member

Group policy member 4

Remove

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

Add another policy member

Group policy member 5

Remove

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

Add another policy member

Group policy member 6

Remove

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

Add another policy member

Group policy member 7

Remove

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

Add another policy member

Group policy member 8

Remove

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

Add another policy member

Group policy member 9

Remove

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

Add another policy member

Group policy member 10

Remove

Title (required)

First name(s)

Surname

Telephone number Enter the member’s phone number.

Email address Enter the member’s email address (required).

Date of birth

Occupation

Add your occupation

A maximum of 10 policy members is allowed. If you require coverage for more than 10 members, please contact us directly.

Membership details

Membership start date

Beneficiary for Live Cover

£100 per week£250 per week

Premium and payments

Payment frequency MonthlyQuarterlyYearly

Premium £18.95 Monthly

Please enter the nominated bank details for the direct debit you wish to use to set up this Group membership plan.

Bank Account Name

Bank Name

Account Number

Sort Code

Please read the declarations and confirm your consent

Please read the declarations below and confirm your consent.

I confirm all the personal information provided about myself is true and accurate

I understand and agree that the product meets my demands and needs, it provides me with a sickness benefit payments if I am unable to work due to certain circumstances and the level of cover provided is not designed to replace my total income

I confirm I have read and understood the Key Fact Document and confirm no advice has been given to me by the Society

I confirm I am employed, self-employed or seeking employment and to the best of my knowledge fit to work

I declare that I have not been diagnosed with a terminal illness and am/or will not be undergoing any investigation related to a terminal illness

I understand that this application shall form the basis of the contract between me and the Society and that failure to disclose any facts that may be regarded as material (i.e., facts likely to influence the acceptance of this proposal) may cause the insurance and Society membership to be declared void

I understand that my membership contract will not commence until this application has been accepted and the first contribution paid

Digital signature: Please type your full name into this box

Email VerificationMobile SMS Verification

Email verification

To complete your claims submission:

Press the green verification code button below
We will send a verification code to the email address used on this claim form
If the email address is incorrect or blank please contact our membership support team on 01474 567050 or email us at info@graveshamfriendly.co.uk and we will update your membership contact details.
Copy and paste or key in the verification code from the email into the verification code box below and press submit.

Verify Code (required)

Once this form is submitted you will be redirected to a page containing our bank details for payment.

Completing this form will not result in you receiving additional marketing information from us.

Proof of name	Proof of address
Current signed passport	Utility bill (gas, electric, satellite television, landline phone bill) issued within the last three months.
Current UK or EEA photocard driving licence	Local authority council tax bill for the current council tax year.
Full old-style driving licence	Bank, Building Society or Credit Union statement or passbook dated within the last three months.
Original birth certificate (UK birth certificate issued within 12 months of the date of birth	Original mortgage statement from a recognised lender issued for the last full year.
Benefit book or original notification letter from Benefits Agency	Council or housing association rent card or tenancy agreement for the current year.
Residence permit issued by the Home Office to EEA nationals on sight of own country passport	NHS Medical card or letter of confirmation from GP’s practice of registration with the surgery.
National identity card bearing a photograph of the applicant	Benefit book or original notification letter from Benefits Agency (but not if used as proof of name).
	HMRC self-assessment letters or tax demand dated within the current financial year.

Join now

Do you need help completing this form?

Would you prefer an offline application?

Registered business address

Scheme administrator

Membership details

Premium and payments

Please read the declarations and confirm your consent

Email verification

Mobile SMS verification