I hereby apply for a Compass Savings Plan.  I confirm that I have read the Plan's Key Features Document.

I declare that :-

a) I am in good health and free from any adverse mental or physical condition, and have neither consulted a specialist nor attended hospital for any serious illness or operation nor received medication other than for minor ailments within the last 5 years, and

b) the total amount of premiums I am currently paying to tax-exempt friendly society policies (including premiums payable under this Application) do not exceed £25 per month or £270 per annum.

I understand that the above Application and Declaration shall form the basis of the contract between myself and the Society.

Applicant’s signature ................................................................. Date ........................................................

If any part of this Application or Declaration does not apply in any respect, you should sign it and give any relevant information on a separate sheet of paper.

Warning - non-disclosure of a material fact (that is, one which an insurer would regard as likely to influence the assessment and acceptance of this Application) may affect the benefits payable. If you are in any doubt as to whether a fact is material you should disclose it.

Compass Friendly Society Limited, Old Bank House, 59 High Street, Odiham RG29 1LF

Authorised and Regulated by the Financial Services Authority

Please print off the completed Form before proceeding to the Standing Order Form    NEXT a

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Release date 09/11/04