Health Cash Plan Application

Title *

Mr
Mrs
Miss
Ms

First Name *

Last Name *

Address *

Address Line 1

Address Line 2

City / Town

Post Code

Email Address *

Email

Confirm Email

Membership Number

(if existing Member)

Date of Birth *

Phone Number *

National Insurance Number

Garage / Depot *

Current Occupation *

Employee Number

Partner's Details (Must permanently live with you)

Title

Mr
Mrs
Miss
Ms

First Name

Last Name

Date of Birth

Occupation

Email

Confirm Email

Phone Number

Free Cover for up to 4 of your Children (Must be under the age of 18 and permanently live with you)

Do you wish to add their details now? *

Yes
No, I will do it later

General Data Protection Regulation – Consent for Use of Personal Data

The Transport Friendly Society Limited (the Society) collects your personal information when you apply for a product with us. The information disclosed by you in this application will be used by the Society to set up and manage the product you have applied for. The Society will not share your data with any third parties for any purposes subject to its legal or statutory obligations. If you would like more information on how the Society uses your personal information, please see our Privacy Notice which can be found on our website.

The Society may wish to contact you in the future with marketing information relating to its other products and services that may be of interest to you. However, the Society will only do this if you are happy to receive such information.

Once your marketing preferences have been updated they will remain in place until you let the Society know otherwise. You can update the Society at any time, opting in or out of marketing, or change the ways in which you would prefer the Society to contact you.

You can update your marketing preferences by contacting the Society:

Phone: 020 7833 2616

Email: info@tfs.uk.com

If you wish to hear about such products please tick the boxes below. If you do not wish to be added to our marketing list, simply leave the tick boxes below empty.

I am happy to be contacted and prefer to be contacted by:

Email
Post

Medical Declaration

Do you or your partner or insured children (where applicable) suffer from any disease, illness or injury that you have received medication, advice or treatment for, or experienced symptoms of, irrespective of whether the condition has been diagnosed in the last 12 months?

General Declaration

I declare to the best of my knowledge and belief that the above statements are true and complete and that I, my partner and children (as applicable) are now in good health.

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

I also understand that the contract will not commence until this application has been accepted and the first premium paid.

I further declare that no advice has been given to me by the Society and that this purchase is on an Execution Only basis.

I agree to conform to the rules of the Society.

Signature