Request for a Pension Estimate Form Employer Employee Name Employee Staff Number If you have more than one Number, please list Date of Birth DD / MM / YYYY National Insurance Number Employee Address Employee Phone Number Date of illustration of Pension Benefits DD / MM / YYYY (e.g. Estimated Date of Retirement Have you requested an Yes No Estimate in the past 12 months? Pension Scheme (if known) Have you any Special Class Yes No status? Do you currently have Practitioner* service, or have Yes No you had Practitioner service in the past? Do you intend to retire in the Yes No next 12 months? * Practitioner Service relates to General Practitioners (i.e. GPs) Reason for Pension Estimate Request (please check one of the following): I am within 5 years of normal retirement age I am considering Voluntary Early Retirement I am involved in Divorce Proceedings or Dissolution of a Civil Partnership (See note 5 below) I have applied for Ill Health Retirement (please specify in the box below)
Request for a Pension Estimate Form Employer Employee Name Employee Staff Number If you have more than one Number, please list Date of Birth DD / MM / YYYY National Insurance Number Employee Address Employee Phone Number Date of illustration of Pension Benefits (e.g. Estimated Date of Retirement DD / MM / YYYY Have you requested an Estimate in the past 12 months? Yes No Pension Scheme (if known) Have you any Special Class status? Yes No Do you currently have Practitioner* service, or have you had Practitioner service in the past? Yes No Do you intend to retire in the next 12 months? Yes No * Practitioner Service relates to General Practitioners (i.e. GPs) Reason for Pension Estimate Request (please check one of the following): I am within 5 years of normal retirement age I am considering Voluntary Early Retirement I am involved in Divorce Proceedings or Dissolution of a Civil Partnership (See note 5 below) I have applied for Ill Health Retirement (please specify in the box below)
REQUEST-FOR-PENSION-ESTIMATE-FORM-V3-Blank-form-for-MANUAL-COMPLETION-ONLY.docx