<% Option Explicit Dim strFullName Dim strAddress1 Dim strAddress2 Dim strAddress3 Dim strPostCode Dim strDateOfBirth Dim strPaymentMethod Dim strNomFullName Dim strNomTitle Dim strNomSurname Dim strNomForename Dim strNomAddress1 Dim strNomAddress2 Dim strNomAddress3 Dim strNomPostCode Dim blnLifeInsuranceCover Dim strBody Dim Mail If Request.Form("Submit") <> "" then strFullName = Trim(Request.Form("FullName")) strAddress1 = Trim(Request.Form("Address1")) strAddress2 = Trim(Request.Form("Address2")) strAddress3 = Trim(Request.Form("Address3")) strPostCode = Trim(Request.Form("PostCode")) strDateOfBirth = Trim(Request.Form("DateOfBirth")) strPaymentMethod = Trim(Request.Form("PaymentMethod")) strNomTitle = Trim(Request.Form("NomTitle")) strNomSurname = Trim(Request.Form("NomSurname")) strNomForename = Trim(Request.Form("NomForename")) strNomAddress1 = Trim(Request.Form("NomAddress1")) strNomAddress2 = Trim(Request.Form("NomAddress2")) strNomAddress3 = Trim(Request.Form("NomAddress3")) strNomPostCode = Trim(Request.Form("NomPostCode")) blnLifeInsuranceCover = Trim(Request.Form("LifeInsuranceCover")) strNomFullName = "" If strNomTitle <> "" then strNomFullName = strNomFullName & strNomTitle & " " End If If strNomForename <> "" then strNomFullName = strNomFullName & strNomForename & " " End If If strNomSurname <> "" then strNomFullName = strNomFullName & strNomSurname & " " End If Set Mail = Server.CreateObject("Persits.MailSender") 'Mail.Host = "mail.fireofficers.org.uk" Mail.Host = "127.0.0.1" Mail.From = "admin@progresswebdesign.co.uk" Mail.FromName = strFullname Mail.AddAddress "foa@fireofficers.org.uk" 'Mail.AddAddress "gavin_404@hotmail.com" Mail.Subject = "Insurance Application from FOA Web Site" strBody = "" strBody = strBody & "Name: " & strFullName & vbcrlf strBody = strBody & "Address: " & strAddress1 If strAddress2 <> "" then strBody = strBody & ", " & strAddress2 End If If strAddress3 <> "" then strBody = strBody & ", " & strAddress3 End If strBody = strBody & vbcrlf strBody = strBody & "Post Code: " & strPostCode & vbcrlf strBody = strBody & "Date of Birth: " & strDateOfBirth & vbcrlf strBody = strBody & "Payment Method: " & strPaymentMethod & vbcrlf & vbcrlf strBody = strBody & "NOMINATION FOR DEATH BENEFIT" & vbcrlf strBody = strBody & "Name: " & strNomFullName & vbcrlf strBody = strBody & "Address: " & strNomAddress1 If strNomAddress2 <> "" then strBody = strBody & ", " & strNomAddress2 End If If strNomAddress3 <> "" then strBody = strBody & ", " & strNomAddress3 End If strBody = strBody & vbcrlf strBody = strBody & "Post Code: " & strNomPostCode & vbcrlf & vbcrlf If blnLifeInsuranceCover <> "" then strBody = strBody & "Life Insurance Cover Requested" End If Mail.Body = strBody On Error Resume Next Mail.Send If Err <> 0 Then Response.Write "Error encountered: " & Err.Description Else Response.Redirect "application_response.asp" End If End if %> The Fire Officers’ Association
Insurance Application Form

Thank you - your application form has been successfully submitted. Click here to download the Direct Debit form.

Association Insurance Scheme

The scheme provides good value; low cost insurance for four types of risk covered for one combined monthly premium. See the subscription and premium rate scales on page 6.

NB. These highly preferential rates are available to fully paid up members only.

1. Accident / Injury
Benefits: On Duty Accident / Injury £35 per week } Subject to 28 day
Off Duty Accident / Injury £21 per week } qualifying period
Accidental Death £20,000
Loss of Limb(s) or Eye(s) £20,000
Total Disablement £20,000

2. Sick Pay
Benefits: £75 per week for a period of 26 weeks commencing in the first week when pay is reduced to half under the appropriate Regulations. The benefit ceases after 26 weeks payment or an earlier discharge from the service or return to duty.

3. Travel Insurance (UK and World Wide)
Benefits: This cover is provided on an annual basis and will apply to member, member’s spouse and dependant children under 21 years of age if travelling with the member or spouse. Cover is provided for a maximum period of 60 days in any one-year commencing 1st January, but this may be extended subject to confirmation prior to travel.

4. Family Legal Expenses
Benefits: To cover various types of non-service related situations.


Additional Option – Life Insurance

Members of the Group Insurance Scheme are also eligible for low cost life insurance, and is available for the member and spouse/partner.

£75,000 cover : £20.00 per month
 £50,000 cover : £13.50 per month

Further details and application form available from Head Office by ticking the box on page the insurance application form. Download Life Insurance Application Form.


Application to Join the Association Insurance Scheme
Personal Accident – Sickness – Travel Insurance (* indicates mandatory field):

I, the undersigned, wish to become a member of the Group Insurance Scheme and declare that I am in good health. I do not suffer from any physical defect or infirmity and I will accept the Insurer’s Policy subject to its terms and conditions.

Name*
Address*
Post Code*
Date of Birth*
Method of payment:*
Monthly
  (please tick one)
Annually
Nomination for Death Benefit:
Title*
Surname*
Forename(s)*
Address*
Post Code*
Please tick box if you require details of Life insurance cover: