death benefit form Survivor's Benefit Plan The Board of Directors reserve the right to change the above terms and conditions. Exclusions and Limitations Benefits will not be honored: Commits suicide Dies as a result of drugs/substance abuse. There is an epidemic in the country. There is an excessive number of deaths due to a natural disaster. Civil Disturbance(s), Rioting or war are responsible for an excess number of deaths. PRODUCTS AVAILABLE Ordinary Shares Permanent Shares Fixed Deposit Ordinary/Quickcash Deposit Christmas Club Junior Savers Account Junior Savers Challenge Loans DECLARATION I hereby agree with the above terms and conditions and furthermore declare that the information given in this application is true and correct to the best of my knowledge and belief. I understand that failure to disclose information will deem this contract null and void and the Death Benefit will be dishonored. Participant's Signature: ____________________________Date Date Format: MM slash DD slash YYYY Witness: ________________________________Date Date Format: MM slash DD slash YYYY Information Verified By: _____________________________Date Date Format: MM slash DD slash YYYY Bay Street P.O. Box 835 Kingstown St. Vincent & the Grenadines Phone: 784-485-6840/784-534-7228 Fax: 784-451-2743 Email: email@example.com Find us on facebook.com Name First Middle Last Date of Birth Date Format: DD slash MM slash YYYY Age as of Last BirthdayAre You Suffering From Any Terminal Ailment?YesNoIf Yes, Please State.NomineeIn the event of death, I hereby nominate the following person(s) as beneficiaries of the plan:(1)Name First Last Address Street Address Percentage(2)Name First Last Address Street Address Percentage(3)Name First Last Address Street Address Percentage(4)Name First Last Address Street Address PercentageTerms And Conditions Every applicant must be a member of the SVG Police Co-operative Credit Union, and shall be: (a) Not younger than sixteen (16) years of age. (b) Shall not be in their sixty first year. Participating members are required to save a minimum of three hundred dollars ($300.00) per annum in their ordinary share account, excluding the annual Death Benefit fee. A person upon becoming a member of the SVG Police Co-operative Credit Union Limited automatically becomes a participant of the Survivors Benefit Plan by paying a contribution of $25.00, which would be transferred on or before January 31st annually until death. New members to the Credit Union who are 55 years but less than 60 years may participate in the plan but the benefit paid will be reduced to 50% of the amount. The Board of Directors reserves the right to deny participation if it is known that the applicant is suffering from an illness which is considered terminal. The Death Benefit grant is $5,000.00, when it becomes payable, payments will be made to the named beneficiary(ies). A claim must be filler out and supported by: The death certificate The deceased ID Card The claimants' ID Card The deceased passbook may also be required Payment of the Survivors Benefit Grant shall only be made: (a) Upon proper identification of Beneficiary, or (b) Upon submission of a copy of the Grant of Probate or letters of Administration to Executor or Administration of the Estate of the deceased. Where the deceased member was a resident out of state, a duly authorized legal representation shall submit the documents as requested by subsection (5) and (6) as appropriate.