By completing this form you confirm that you wish to change the terms of your existing Mutual Fund Agreement. The changes you select in this form will be effective from 1st April 2015 - 31st March 2016. 1. School Name2. School DCSF Number3. Your Name4. I wish to change from our existing Cover for Absence - Schools Mutual Fund Scheme to the level indicated on this form. I understand the premium is based on January numbers of staff pay factor rates as confirmed by payroll (January 2015). 5. Teacher Cover: A -100% B - 120% C - 80% 6. Support Cover (as of 1st April 2013 this level of cover will also include caretakers, cleaners, meal time assistants and cooks where the pay factor rate is 0.4 and above) A - 100% B - 120% C - 80% D - No Cover 7. Caretakers, cleaners, meal time assistants and cooks cover where the pay factor rate is 0.3 and below: Yes No 8. I confirm that I have read and agreed the terms and conditions of joining the Schools Mutual Insurance Fund Scheme. 9. Form completed by Business Manager Chair of Governors Head Teacher CaptchaAfter completing this form please ensure you click on the 'send form' button. You will receive an email confirming receipt of this form shortly. If you do not receive this email in the next 5 working days please contact the Mutual Fund Team on 01392 382784. Δ