BUPA Cashplan

BUPA Cashplan
Please complete this form if you would like to sign up to BUPA Cashplan from 1 April 2022. Please note by signing up to this benefit you understand this is a benefit in kind and will appear on your P11D.
Name:*

First NameLast Name
DOB:

DayMonthYear
Date
Phone Number
Please enter a valid phone number.
Department:*
Address: (BUPA will send your member pack here)*

First Line Address

Second Line Address

CityCounty

Post Code
Level of cover:*

Level 1 (provided by Corrigenda)Level 2 (additional cost of £11.75 to you per month)Level 3 (additional cost of £27.87 to you per month)Family level 1 (additional cost of £12.66 to you per month)Family level 2 (additional cost of £29.60 to you per month)Family level 3 (additional cost of £63.53 to you per month)
Please complete this section of the form for up to 4 child dependants. Your dependants must be under 24 years old and live permanently in the UK.
Number of Dependants:
Name of Dependant 1:

First NameLast Name
Date of Birth for Dependant 1:

DayMonthYear
Date
Name of Dependant 2:

First NameLast Name
Date of Birth for Dependant 2:

DayMonthYear
Date
Name of Dependant 3:

First NameLast Name
Date of birth for Dependant 3:

DayMonthYear
Date
Name of Dependant 4:

First NameLast Name
Date of birth for dependant 4:

DayMonthYear
Date
Email Name Alert:

First NameLast Name
Email Alert:
example@example.com
Should be Empty: