LAB/ DOPS Claim Notification Form

Intermediary details (if applicable)

Intermediary's name:

Intermediary's telephone number:

Intermediary's email address:

Is this Life Assurance Benefit only or Life Assurance Benefit and Dependant's Pension Benefit or Dependant's Pension Benefit only?

About the scheme

Policyholder name:

LAB policy number G (please only type the 8 numerical digits after the G):

The Group Protection policy number will start with a G and contain 9 numbers.

Date the deceased became a member of the LAB scheme (DD/MM/YYYY):

This is the date that the deceased joined the scheme

LAB Membership category at date of death?

Date of entry into LAB category (DD/MM/YYYY):

DOPS Policy Number G (please only type the 8 numerical digits after the G):

The Group Protection policy number will start with a G and contain 9 numbers.

Date the deceased became a member of the DOPS scheme (DD/MM/YYYY):

This is the date that the deceased joined the scheme

DOPS Membership category at date of death?

Date of entry into DOPS category (DD/MM/YYYY):

Member details

Deceased's surname:

Deceased's forename:

Selection

Gender

Deceased's address:

Date of birth (DD/MM/YYYY):

Date of death (DD/MM/YYYY):

Cause of death (as per death certificate):

Date of entry into service (DD/MM/YYYY):

This is the date the member commenced their employment

Date the deceased was last actively at work (DD/MM/YYYY):

This means the employee must be in full active employment, physically and mentally able to perform all the duties associated with their normal job.

Reason for any absence between date last actively at work and date of death:

Deceased's occupation:

Address of where deceased was last employed:

Was the death abroad?

You only need to complete this section if the death occurred overseas. Please ensure that you send the original death certificate along with an official translation otherwise the claim could be delayed. We may ask you to complete a death abroad questionnaire in order for us to process your claim.

Date of departure from the UK (DD/MM/YYYY):

Country where death occurred:

Intended date of return to UK (DD/MM/YYYY):

Purpose of visit:

Life Assurance Benefit

Life Assurance Benefit scheme earnings at date of death (Please only include the numeric value e.g. 18,500.25):

Please provide the member's scheme earnings as per the date of death

Life Assurance Benefit scheme earnings at renewal prior to date of death (Please only include the numeric value e.g. 18,500.25):

Life Assurance Benefit amount claimed (Please only include the numeric value e.g. 18,500.25):

This is the sum that you will be claiming under the scheme

Life Assurance Benefit basis of calculation:

Would you like to pay direct to beneficiaries? (If you select yes, a member of our team will contact you to request the required information and you will not be required to complete the bank details below)

Trustee bank sort code (eg 123456):

Trustee's bank account number (eg 12345678):

Trustee's bank account name:

Dependant's pension

Name of dependant:

Date of birth (DD/MM/YYYY):

Gender:

Address:

NI number:

Please provide the NI number of the dependant

Relationship to the deceased:

e.g. Wife, Husband, Son, Daughter

Dependant’s pension scheme earnings (Please only include the numeric value e.g. 18,500.25):

Please provide the member's scheme earnings

DOPS amount claimed (Please only include the numeric value e.g. 18,500.25):

This is the sum that you will be claiming under the scheme

DOPS basis of calculation:

Pension increase rate and if, separate rates apply to different portions of pension, the rates applicable to each:

Would you like this to be paid as a lump sum (if scheme rules apply):

Dependant's bank account sort code (eg 123456):

Dependant's bank account number (eg 12345678):

Dependant's bank account name:

Are there multiple dependants? (If you select yes, a member of our team will contact you to request the required information)

Declaration

The benefit claimed should be payable in accordance with the contact(s) of insurance.

The policyholder should make sure the deceased was eligible and that, where earnings related, the benefit claimed is calculated in accordance with the definition of scheme earnings agreed for insurance purposes.

I agree to provide Legal & General’s Privacy Policy to the beneficiaries of a dependant’s pension.

Name:

Capacity in which signing (eg Trustees, Scheme administrators):

Phone number:

Email address: