PENSIONER TERMINAL ILLNESS FULL PAYMENT FORM

PENSIONER TERMINAL ILLNESS FULL PAYMENT FORM
PLEASE READ THIS SECTION BEFORE YOU START COMPLETING THIS FORM. The Trustee will only authorise payment of your Terminal Illness benefit if, after considering relevant medical evidence, it considers you are suffering an illness that poses a serious and imminent risk of death.
1. Pensioner details
RMD Number
CINSF Member Number
Title
First name(s)
Surname
Date of Birth (DD/MM/YY)

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
Physical Address
Home Phone

Country CodePhone Number
Mobile Phone

Country CodePhone Number
Email Address
example@example.com
Step 2 - Payment Details:

Bank Name
Bank Number
Branch
Branch number
Account Number
Account Name
Swift Code (overseas accounts only)
Bank Address (overseas accounts only)
Step 3- Terminal Illness for Pensioners:
For a Terminal Illness full payout:
- ask your doctor to complete the declaration below.
DOCTOR'S DECLARATION OF TERMINAL ILLNESS FOR PENSIONERS
PATIENT
Full Name

First NameLast Name
Patient Residential address
Address
Practice/Clinic Name
DOCTOR
I, Doctor
of

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone

Country CodePhone Number
Mobile

Country CodePhone Number
Email Address
example@example.com
Certify that:
- I am registered medical practitioner with the Medical Council of the Cook Islands or with an equivalent registration regime outside the Cook Islands.
- the above-named is a patient of mine and I have recently given them a full medical examination.
- In my opinion, the above named has a terminal illness that poses a serious and imminent risk of death
Signature of Medical Practitioner
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Step 4 - Declaration
I certify that the information I have provided on this form is true and correct.
Signature
Full Name

First NameLast Name
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year