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Death in Service Nomination Form

We want to provide financial support to our colleagues in the event they pass away whilst in our employment, we will do this through our Death in Service scheme. Eligible colleagues should complete the below form to provide us with details of the nominated individual who should be contacted and receive any financial payment.

It is your own responsibility to complete this form and return it your Home Administrator. You must make us aware of any changes in the personal details of your nominated individual by completing an updated form. Not providing us with completed and up to date nomination form may impact the chance of your nominated individual receiving any financially support from us. You must have gained consent from your chosen individual for their personal data to be shared and held on file by Christadelphian Care Homes before completing this form. Should you leave our organisation the information you have shared about your nominated individual will be securely destroyed.

Your Details

Please provide your contact details below. We will use this information to create your employee profile.

Date Of Birth

Start date with CCH

Criminal Record Declaration

You have been asked to complete this form because the role you are employed in is exempt from the Rehabilitation of Offenders Act 1974. The information disclosed will be treated in the strictest of confidence and will only be disclosed to the Home Management team and/or the HR Team.

Your Nominated Individual Details

Date Of Birth

Declaration

Statement on Employing Applicants with Criminal Records

Your role is exempt from the Rehabilitation of Offenders Act 1974 and therefore you are required to declare: All unspent convictions and conditional cautions. All spent convictions and adult cautions that are not protected (i.e. that are not filtered out) as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended in 2020).

Please be aware that deliberate attempts to conceal the information requested in this form could result in disciplinary proceedings or dismissal.

I declare that the information provided on this form is correct. I will keep Christadelphian Care Homes up to date should my circumstances change at any point throughout my employment.

Yes