Election To Purchase Additional Pension

Employer(Required)

Please ChooseNIFRSHSC

Section 1 - Personal Details

Name(Required)

Dr.MissMr.Mrs.Ms.Mx.Prof.Rev.They/Them Prefix First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Date of Birth(Required)

MM slash DD slash YYYY

National Insurance Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Work Location

Payroll//Staff/Service Number(Required)

Gender

Male

Female

Other

Current Employer

Section 2 - Choice of Options

I wish to purchase an additional sum of £* per annum(Required)

(up to a maximum of £6,500 in multiples of £250) Please note that if you have an existing Early Retirement Reduction Buy Out (ERRBO) this may impact on the amount of the maximum additional pension that may be purchased

I wish to purchase addition pension for (tick one only)(Required)

Personal Benefits Only

Personal Benefits and Dependant Benefits

I wish to pay by (tick one only)(Required)

A one off payment*

Installments from my salary **

**If payment is to be made by instalments please state number of whole years over which payments are to be made below. This can be any period from 1 year up to 20 years and can end no later than the day before your State Pension Age. *Please note if the payment is by a one off lump sum then it must be received within one month of you receiving the acceptance letter from BSO NIFRS Pension Team.

I wish to make instalments over x years (as detailed above).

Section 3 - Members with Multiple Contracts of Employment (complete if applicable)

If you are currently working for more than one employer please specify the employment that deductions should be taken from.

Section 4 - Verification

Verification of Date of Birth(Required)

Max. file size: 20 MB.

Please supply us with a copy of your Birth Certificate with this application form so that we can verify your Date of Birth. We will be unable to process any applications until we receive this document.

Section 5 - Declaration

Agree(Required)

To the best of my knowledge the information given in this form is true. I have no reason to believe that my health prevents me from continuing in pensionable employment until the payment period is completed.

Please note: The actuarial factors used to calculate additional pension are based on a normal retirement age which is linked to your State Pension Age, therefore if you take out an additional pension contract and then retire between the minimum retirement age and normal pension age for the scheme your additional pension will be reduced accordingly.

Phone

This field is for validation purposes and should be left unchanged.