Apply For help

Personal Details
Name

TitleFirst NameLast Name
Personal email
example@example.com
Do you have a PPS or NI Number?
NI Number
PPS Number
Preferred Telephone Number
MaritalStatus
Single
Date of birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Relationship Status
Partner Name

TitleFirst NameLast Name
Partner NI Number
Partner PPS Number
Partner Date Of Birth

DayMonthYear
Do you have any dependant children?
Dependant children
Are there any other adults residing at this address (including children over 18)?
Details of adults

Details of insurance service
Name of the person on whose insurance service this application is based

TitleFirst NameLast Name
Insurance Employment
Employer Address

Street Address

Street Address Line 2

CityCounty

Postcode
Employee/pensioner reference number (if known)

Reason For Application
Reason
Please Specify

0/100
Where did you hear about us?
Overview of the misfortune that has occurred

0/400
Have you applied to The Insurance Charity before?
When did your help from The Insurance Charity cease?
Please give details of your employment since your help ceased
Have you applied to any other organisations or charities before?
Details of organisations or charities approached for assistance
Declaration
I confirm that the information submitted in this application enquiry is true and correct. I confirm that I will inform the Charity of any change in circumstances during the application process. I understand that the Charity may cease its consideration of my application should there be any misstatement of facts and will retain the right to contact any appropriate third party in the event of any suspected fraud, as well as reclaim any funds advanced which otherwise would not have been made.
Authorisation
I authorise the Charity to supply details of this application to any other charity for the purpose of assisting with the application. I also authorise my creditors and any other person with knowledge of my financial and personal circumstances to disclose to the Charity any requested information in consideration of this application.
Should be Empty:

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