Westfield Health

Please complete this form if you wish to join the Westfield Health Scheme.

This scheme is free to all Childbase Partnership colleagues with 3 years service. You have the option to add your partner and/or dependent children to the scheme.

Your Details

Name(Required)

Prefix First Last

Date of birth(Required)

Home address(Required)

Address line 1 Address line 2 Town/City County Postcode

Your Health

Confirmation of any illness’s or injuries in the past two years(Required)

Employment

Nursery/location(Required)

Job title(Required)

Personnel number(Required)

Start date

Optional

Please select if required

ADDITIONAL COVER Please complete the partner and/or children sections below. If you are applying for both your partner and children you only need to complete one form. CHILDREN ONLY Childbase Partnership will cover any children aged under 18 who are financially dependent on you. If you wish to add your dependent children to Westfield Health please download the form here. Once completed please return it to sally.parish@childbase.com at Head Office. PARTNER If you wish to add your partner to Westfield Health please download the form here. Once completed please return it to sally.parish@childbase.com at Head Office. Please fill in your partner’s details below and confirm that you would like to pay via salary deductions.

Partners name

First Last

Partners date of birth

Pay date to commence

I agree to the monthly premium being deducted from my salary each month and understand if I wish to cancel the arrangements during the course of the year. I also agree that if there is an increase in insurance premiums during the period, an adjustment will be made to the agreement.

The current monthly cost is £31.33 per month.

Signature

Date

Confirmation

By signing below I confirm all information is accurate.(Required)

Date