Death in service form

Yes – Move onto next question
No – Further question below: Please cancel this transaction and check the member address. If it is incorrect, please correct it before attempting this transaction again.

Please enter one the following ranks:

Firefighter Trainee
Firefighter Development
Firefighter Competent
Crew Manager Development
Crew Manager Competent
Watch Manager Development
Watch Manager Competent A
Watch Manager Competent B
Group Manager Development
Group Manager Competent A
Group Manager Competent B
Station Manager Development
Station Manager Competent A
Station Manager Competent B
Area Manager Development
Area Manager Competent A
Area Manager Competent B
Assistant Chief Fire Officer
Deputy Chief Fire Officer
Chief Fire Officer

Civil Partnership
Cohabiting Partner
Married
Not Married
Unknown

Enter any dates in the format dd/mm/yyyy

Date of strike (dd/mm/yyyy)

Hours on strike

Add another?

• No/Yes

Total number of days strike

Strike contributions being repaid?

• No/Yes

Total number of hours strike
Pay lost due to strike £

Was member in receipt of LSI at 30 June 2007?

• No/Yes

Is member in receipt of CPD?

• No
• Yes - Total pension contributions relating to the CPD payment
  (Employee, Employer & Notional Ill Health percentages) from 1 July to date of leaving £

Is there any other pay deemed pensionable via an APB (from 01/07/2013) i.e. Temporary Promotion? *

• No
• Yes - Total pension contributions relating to the 'Temporary payment' (Employee, Employer & Notional Ill Health percentages) from 1 July to date of leaving

Average pensionable pay up to date of death

Date from (dd/mm/yyyy) Annual Pay £

Date from (dd/mm/yyyy) Annual Pay £

Date from (dd/mm/yyyy) Annual Pay £

No – Move onto next question

Yes –

• Date from (dd/mm/yyyy) Annual pay £
• Date from (dd/mm/yyyy) Annual pay £
• Date from (dd/mm/yyyy) Annual pay £

Date from (dd/mm/yyyy)

Date to (dd/mm/yyyy)

Amount £

No – Move onto next question

Yes

Repaying by periodical payment?

No - Move onto next question

Yes

• Date of first payment (dd/mm/yyyy)
• Amount of monthly payment £
• Date final payment will be deducted (dd/mm/yyyy)

Continue

No – Move onto next question

Yes

• CPP for current financial year i.e. from 1st April until date of death: £

No – Move onto next question

Yes

• APP for any previous financial year
• Year (yyyy) APP £
• Year (yyyy) APP £
• Year (yyyy) APP £
• Year (yyyy) APP £

No – submit form

Yes – further question below

• Please give details of the outstanding contributions here: £