HEALTHCASHPLAN 5.00 DENTAL OPTICAL THERAPY AND APPLICATION FORM CLAIM CASH TOWARDS YOUR EVERYDAY HEALTHCARE BILLS SUCH AS TREATMENTS

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1 HEALTHCASHPLAN APPLICATION FORM CLAIM CASH TOWARDS YOUR EVERYDAY HEALTHCARE BILLS SUCH AS DENTAL OPTICAL THERAPY AND TREATMENTS COVER STARTS FROM AS LITTLE AS 5.00

2 Let us help with the cost of your everyday healthcare GREAT VALUE EXTRA BENEFITS HOW MY HEALTH CASH PLAN HELPS ME I go to the osteopath every two months to help with the damage done to my back, by years of leaning over a computer. The benefits are enormous. My back pain has gone and I can now see to the side without having to turn around. With each session costing 42, my health cash plan is helping me maintain a major improvement in my physical wellbeing. BHSF policyholder With a health cash plan you can claim cash towards dental check-ups and treatment, eyesight tests, new glasses, contact lenses and therapy treatments such as physiotherapy and chiropody. You can claim cash reimbursements for routine and emergency healthcare. You do not need to be ill to benefit from a health cash plan, but if you do have an unexpected illness you can claim towards the cost of a diagnostic consultation, or towards the expenses associated with a stay in hospital or day-case surgery. It doesn t matter whether you have your healthcare through the NHS or privately, a health cash plan can help you. Five levels of cover to choose from Any PCS Union member aged 17 or over, who normally resides in the United Kingdom, can apply. Personal and Family cover children can be covered on a family plan until their 18th birthday No medical required We authorise payment of 90% of eligible claims within two working days of receipt Cover starts from as little as 5.00 per month Premiums payable through convenient payroll deduction Claim from the start date of your policy. For maternity payment, you will need to wait 10 months from the policy start date and if you have an existing medical condition, you will have to wait two years before you are covered for hospital-related claims. I CAN SPEAK TO A GP WHEN I NEED TO I ve used this service four times in the last year. The last call was for my wife; we called at 7am and a doctor called back within 25 minutes. This saved the inconvenience of trying to get a doctor s appointment and the problem was addressed over an hour before our local surgery even opened. Unless I need to see my GP in person, I would use this facility every time from now on. BHSF policyholder GP HELPLINE We all know that contacting your GP for medical advice, reassurance or guidance, especially outside of surgery hours or during the working day, can sometimes be difficult. Even after you ve called the surgery, you may face a long delay to get an appointment or have to take one at an inconvenient time. The GP helpline provides 24/7 telephone access to professional advice by a fully-qualified GP. Also included is access to an online webcam consultation with a doctor. 24/7 TELEPHONE HELPLINE This confidential telephone helpline is available 365 days a year, offering a counselling service on stress, family relationships, substance abuse and debt, along with legal advice and information on financial and health matters too. SONAL ACCIDENT COVER Nobody likes to think about it, but accidents do happen. Included in the health cash plan is personal accident cover, which covers you for certain injuries resulting from accidents such as certain fractures of the arms and legs, permanent disabilities and death.

3 Make the most of a health cash plan LOOK AT THE TABLE OPPOSITE AND SEE WHICH LEVEL OF COVER BEST SUITS YOU AND YOUR FAMILY. THE HIGHER THE LEVEL OF COVER, THE MORE YOU CAN CLAIM. Each insured adult has their own maximum benefit. Children can be included on a family policy until their 18th birthday and where benefit is provided it is limited to once times the maximum amount shared amongst all insured children. No advice has been given by BHSF in relation to the sale of this product. *Unless shown otherwise the maximum amount is payable per Benefit Year. All benefits payable are subject to BHSF policy terms; copies available on request. Immediate benefit with the exception of maternity payment (10 month qualifying period) and for pre-existing medical conditions (2 years). Insurance Premium Tax included at the applicable rate. Issued by BHSF Limited, 2 Darnley Road, Birmingham B16 8TE. BHSF Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation Authority. E&OE OS505 07/14 Monthly Premium (including Insurance Premium Tax) Bronze Silver Gold Platinum Diamond Personal (policyholder only) Family (policyholder, partner and dependent children) Benefits Maximum per Insured Person per Benefit Year/s.* Reimbursement rate Bronze Silver Gold Platinum Diamond Dental 100% Dental trauma 100% ,000 Optical every two Benefit Years 100% Diagnostic consultation 75% Therapies combined maximum benefit including physiotherapy, osteopathy, chiropractic and acupuncture treatment Chiropody, homeopathy and reflexology combined maximum benefit 75% ,200 75% Hospital in-patient up to 35 nights per Benefit Year per night Hospital day-case surgery up to 10 events per Benefit Year per event Recuperation payable automatically after a valid hospital inpatient claim of at least 10 consecutive nights lump sum Maternity (adult benefit only) per child Hearing aids every two Benefit Years 75% Health screening every two Benefit Years 75% Access to care (adult benefit only) - - Personal accident (adult benefit only) up to 25,000 50, , , ,000 Telephone helpline - GP consultation service - Private prescription service - 24 hour, 365 days a year telephone helpline offering a counselling service on stress, family relationships, substance abuse and debt, along with information on a range of issues including legal, financial and medical matters. Providing access to a GP helpline 24 hours a day, 7 days a week. Also includes access to an online webcam consultation available Monday - Friday, 8.30am to 6.30pm (excluding bank holidays). The private prescription service enables its doctors to issue private prescriptions and send them directly to a registered pharmacy for despatch to a patient. Gym membership - Corporate membership rates at over 2,500 participating UK and Ireland gyms and fitness clubs.

4 IMPORTANT INFORMATION The Financial Conduct Authority (FCA) is an independent body that regulates the general insurance industry. It requires us to give you certain information so that you can decide if our services are right for you. This plan meets the demands and needs of those who wish to have assistance towards covering their everyday healthcare costs such as dental check-ups and treatment, eye tests and glasses and complementary therapy fees. In deciding to purchase this product you will not receive advice or personal recommendation from BHSF. This insurance is sold by BHSF Services Limited and underwritten by BHSF Limited. Both companies are part of BHSF Group Limited, 2 Darnley Road, Birmingham B16 8TE. BHSF Services offers this product on a non-advised sale basis only. BHSF Limited of 2 Darnley Road, Birmingham B16 8TE is an insurance company authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation Authority. Our registration number is Our permitted business includes advising on and effecting noninvestment insurance contracts. Details of our registration can be checked at or by telephoning As an insurer, BHSF Limited offers only its own cash plan products in isolation; where appropriate it may offer the most suitable of its products, but only in comparison with other products underwritten by BHSF. No advice has been given by BHSF in relation to the sale of this product. You have 14 days from the date you receive your policy to review it. If you are not completely satisfied with the policy, simply notify BHSF in writing within 14 days and we will cancel it. Provided a claim has not been paid, we will refund any premium collected. BHSF Limited is covered by the Financial Services Compensation Scheme (FSCS). You may be entitled to compensation from the scheme if we are unable to meet our obligations. Entitlement will depend on the type of business and the circumstances of the claim. Further information about the compensation scheme is available on the FSCS website If you wish to register a complaint, please do so in writing to BHSF, 2 Darnley Road, Birmingham B16 8TE or by telephoning , quoting your policy number. If you are not satisfied with the outcome of the complaint, you may refer it to the Financial Ombudsman Service. A Applicants are requested to complete all applicable sections and return the entire form to BHSF, FREEPOST BM2163, BIRMINGHAM B16 8BR. All insured persons must be normally resident in the United Kingdom and reside at the same address. Any dependent children to be covered must be under 18 years of age. 1 Title Surname Forename(s) Address County Telephone 2 Employer s name Employer s address 3 HEALTHSCHEME APPLICATION FORM SONAL DETAILS EMPLOYER DETAILS CHOICE OF COVER Town Please tick the policy of your choice (tick one box only): SONAL POLICY Union membership no. Payroll number FAMILY POLICY OS505 07/14 GROUP NUMBER REP NUMBER PRODUCT CODE BH For more information please call visit or sales@bhsf.co.uk

5 4 COVER FOR YOUR PARTNER AND FAMILY I wish my application to cover my partner, whose full name, date of birth and gender is: Title Surname Forename(s) B PAYROLL DEDUCTION AUTHORITY FORM 7 EMPLOYER DETAILS Employer s name Employer s address I wish my application to cover my children, whose full names, dates of birth and genders are: Payroll number Name Name Name 5 IF YOU ARE, OR HAVE PREVIOUSLY BEEN INSURED BY BHSF Policy number Last premium date Where was it paid? State either employer s name or direct to BHSF 6 DECLARATION I understand that: No hospital-related claim will be paid during the first two years of my policy in respect of any medical condition which existed or was being investigated before cover commenced and BHSF may wish to verify medical information to support a hospital-related claim. If more than three children are to be covered please supply details on a separate piece of paper. I agree to abide by the policy terms, and I acknowledge that they may be varied, as may the range or rates of benefits and/or premiums, if deemed necessary. I declare that all the information I have given in this application is true, and that, if found to the contrary, claims may be rejected or the policy may be cancelled at any time. I understand that my personal information will be used in accordance with the Data Protection Act 1998 by BHSF (and relevant BHSF Group companies) and by other companies who may provide a service under this insurance. This information may also be used for the efficient administration of the insurance, to monitor and continue to improve these services, and for the detection and prevention of fraud. 8 Please deduct the appropriate amount of premium from my pay and apply it to my BHSF policy as follows (tick one box only): Title Surname Forename(s) Address County HEALTH CASH PLAN PREMIUM SONAL POLICY 9 APPLICANT S DETAILS SIGNATURE FAMILY POLICY Payroll number Town I hereby authorise the deduction from my salary/wages of the amount indicated (or such future amounts as may be required to secure the benefits of the plan) each month. Please remit same to BHSF on my behalf at the agreed intervals until further notice from me. This cancels any previous BHSF deductions authorised by me. Please ensure that you have signed and dated this box: SIGNATURE Signature Date Please ensure that you have signed and dated this box: Signature Date PLEASE RETURN THE ENTIRE APPLICATION FORM TO: BHSF, FREEPOST BM2163, BIRMINGHAM B16 8BR We may advise you, from time to time, about other products and services which may be of interest to you. If you do not wish to receive this information please tick the box. BHSF Limited, Darnley Road, Birmingham B16 8TE Tel Fax sales@bhsf.co.uk

6 HOW YOUR HEALTH CASH PLAN WORKS The following examples are based on a Silver personal policy at 9.65 per month. Do you have dental check-ups twice a year? Claim 100% of the cost of regular dental check-ups, treatment or a trip to the hygienist, up to 100 per Benefit Year. Do you wear glasses or contact lenses? CLAIM UP TO 100 CLAIM UP TO 100 Every two Benefit Years you can claim up to 100 towards the cost of eyesight tests, new glasses or contact lenses. If you visit a physiotherapist or chiropractor... Claim back 75% of the cost of therapy treatments up to the combined maximum CLAIM benefit of 350. UP TO 350 The therapies benefit covers physiotherapy, osteopathy, chiropractic and acupuncture treatment. NEXT? WHAT TO DO 1) CHOOSE YOUR COVER Decide which level of health cash plan cover is best for you. Remember, the higher the level of cover the more you can claim. Complete section A of the application form. 2) PAYROLL DEDUCTION Please ensure you complete section B of the application form and remember to sign and date the declaration. 3) POST YOUR FORM Return your completed application form to BHSF, FREEPOST BM2163, BIRMINGHAM B16 8BR. RECEIPT POST CLAIM CASH BACK When paying for your treatment, ensure that you ask for a receipt Fill out your claim form and post it to BHSF along with your receipt We authorise payment of 90% of eligible claims within two working days of receipt VISIT TO REQUEST A CLAIM FORM Dental and optical benefits are payable at 100% of the receipt value and therapies are payable at 75% reimbursement, up to the appropriate maximum benefit under your chosen level of cover. All claims are subject to BHSF policy details; copies available on request.

7 HEALTH CASH PLAN For more information please call visit or BHSF Limited and BHSF Services Limited Both organisations are registered at Darnley Road, Birmingham B16 8TE. Tel: Fax: Web: Calls to our office are recorded and may be monitored for training and security purposes. BHSF Limited authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation Authority. Registered in England number BHSF Services Limited authorised and regulated by the Financial Conduct Authority. Registered in England number BHSF is covered by the Financial Ombudsman Service. FOR OFFICE USE ONLY CAMPAIGN CODE GROUP NUMBER REP NUMBER PRODUCT CODE BH Printed on environmentally friendly material from a sustainable source. OS505 07/14