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SS14 Form for Locums

Notes for the applicant: Please read these before filling in the form.

1. If you were in the HSC Pension scheme and if you are re-joining the scheme within 5 years of leaving it (or longer if you left to take up a study course or approved employed) your earlier employment can count towards your superannuation.
2. If you were in another pension scheme within the past 12 months and now you are joining the HSC Pension Scheme, you may be able to reckon your service in the previous scheme. To do this you must complete this form within 6 months of entering this scheme so that we can ask for a transfer to be arranged.
3. The HSC Pension Scheme Guide can be viewed online at http://www.hscpensions.hscni.net/scheme-guides/
4. All applicants should complete Parts A & B. If you are, or have been a member of the HSC Pension Scheme at any time, complete Part C. if you are or have been a member of another pension scheme (this includes a personal pension) Part D.

If you would rather print and fill out this form by hand, please access this document below:

SS14 Form

SS14 Locum Form

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Part A - Personal Details

Practitioner/Assistant/Locum's Name:(Required)
DD slash MM slash YYYY
DD slash MM slash YYYY
Please Indicate if the post is:(Required)
Email Address:(Required)
DD slash MM slash YYYY
Your Present Address:(Required)

Part B:

Are you Already on the BSO list?(Required)
Are you currently employed in another post in the Northern Ireland Health Service?(Required)
Are you paying superannuation in employment with the Northern Ireland Health Service?(Required)

If you answered 'Yes' to any of the above, please give details:

Are you in receipt of a HSC Pension?(Required)
Please select if you are making additional payments for any of the following:

Part C:

Only complete this section if you were previously a member of the HSC Pension Scheme
DD slash MM slash YYYY
If you left that employment less than 12 months ago have you applied for a refund?
Do you want to repay these contributions so that they count for your Pension?
Did you leave your last HSC employment to take up a course of study or training or to take up employment in which your superannuation rights were protected?

If 'yes' to any of the above, please complete A - C below:

DD slash MM slash YYYY
DD slash MM slash YYYY

Part D:

Complete this section if you are or were previously a member of another superannuation scheme or were contributing to a personal pension.
DD slash MM slash YYYY
If you did not get a return of contributions when you left that superannuation scheme, it may be possible to transfer your service to the HSC Scheme - Do you wish to have a transfer arranged?

Part E:

If you require HSC Pension Service to communicate with any third party on your behalf, this may include your accountant or/and financial adviser, please complete this section.

Declaration

By checking this box, I authorise the above accountancy form and it's representatives to act on my behalf. I confirm that any changes to this instruction will be forwarded to HSC Pension Service without delay. I have also read the HSC Pension Scheme Guide.
Declaration:(Required)
This field is for validation purposes and should be left unchanged.

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