The purpose of this form is to enable you to express your wishes with regard to the payment

of any lump sum death benefit from your Group Life Assurance Scheme. Although the

Trustees may take your wishes into account, the final decision rests with the Trustees.

 1. Employee details

Full Name

Employee Number

2. Details of Beneficiaries

I, the above named plan holder, would like the scheme Trustees to pay any lump sum

death benefit to the beneficiaries named and in the proportions set out below:

Full Name

Relationship to me

Percentage of benefits

Full Name

Relationship to me

Percentage of benefits

Full Name

Relationship to me

Percentage of benefits

Full Name

Relationship to me

Percentage of benefits

3. Declaration

I wish the above to be considered as possible recipients of any lump sum payable on my death at the discretion of the Trustees and where more than one person is named by me then in the proportions indicated. I confirm that I understand that the Trustees can take this expression of wish form into account when deciding how to exorcise its discretionary powers, but is not legally bound to do so. This supersedes any previous expression of wish signed by me.

Date (dd/mm/yyyy)

Signature