Who is this for? This form is for employees of Pearson who have previously opted out of the Plan and would like to re-join. A health declaration is required before your application to rejoin can be considered. Please note that if you complete the declaration incorrectly, it may affect whether you are allowed to rejoin, and/or your entitlement to the benefits available. Once the declaration has been completed and submitted, the Plan Trustee will consider your declaration and you will be contacted accordingly. You will not be able to rejoin the Plan until we have responded. Your details * Denotes required fields Your name Title*MrMrsMissMsDrProfTitle* - This is a required field Forename(s)* - This is a required field Surname* - This is a required field Address Select countryUnited KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaÅland IslandsBhutanBolivia (Plurinational State of)Bonaire, Sint Eustatius & SabaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Democratic Republic of)CongoCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island & McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic)Korea (Republic of)KuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension & Tristan da CunhaSaint Kitts & NevisSaint LuciaSaint Martin (French part)Saint Pierre & MiquelonSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan (Province of China)TajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis & FutunaWestern SaharaYemenZambiaZimbabweCountry* - This is a required field Start typing your address Look up address Address line 1* - This is a required field Address line 2 Town County/State/Province/Region Postcode/Zip code Date of birth* Day* of birth - This is a required fieldDD01020304050607080910111213141516171819202122232425262728293031 Month* of birth - This is a required fieldMM010203040506070809101112 Year* of birth - This is a required fieldYYYY202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886 Other information National Insurance number* - This is a required field For example QQ123456C Email address* - This is a required field What would you like to do? Your health declaration * Denotes required fields Please tick one of the questions below* - This is a required field: I can confirm I have been continuously at work since I opted out of the Plan, and I am not aware of any condition that will affect my ability to complete my job role now or in the future.I can confirm I have been continuously at work since I opted out of the Plan, and that I am aware of a condition that could/will affect my ability to complete my job role now or in the future. Please can you provide details of any medical conditions that could/will affect your ability to complete your job role now or in the future: Medical condition #1 Medical condition #1 fields Medical Condition #1* - This is a required field Date of diagnosis - 1* - This is a required field Day of diagnosis #1DD01020304050607080910111213141516171819202122232425262728293031 Month of diagnosis #1MM010203040506070809101112 Year of diagnosis #1YYYY202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886 Additional Information for medical condition #1 Medical condition #2 Delete medical condition #2 Medical condition #2 fields Medical Condition #2* - This is a required field Date of diagnosis #2* - This is a required field Day of diagnosis #2DD01020304050607080910111213141516171819202122232425262728293031 Month of diagnosis #2MM010203040506070809101112 Year of diagnosis #2YYYY202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886 Additional Information for medical condition #2 Medical condition #3 Delete medical condition #3 Medical condition #3 fields Medical Condition #3* - This is a required field Date of diagnosis #3* - This is a required field Day of diagnosis #3DD01020304050607080910111213141516171819202122232425262728293031 Month of diagnosis #3MM010203040506070809101112 Year of diagnosis #3YYYY202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886 Additional Information for medical condition #3 Medical condition #4 Delete medical condition #4 Medical condition #4 fields Medical Condition #4* - This is a required field Date of diagnosis #4* - This is a required field Day of diagnosis #4DD01020304050607080910111213141516171819202122232425262728293031 Month of diagnosis #4MM010203040506070809101112 Year of diagnosis #4YYYY202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886 Additional Information for medical condition #4 Medical condition #5 Delete medical condition #5 Medical condition #5 fields Medical Condition #5* - This is a required field Date of diagnosis #5* - This is a required field Day of diagnosis #5DD01020304050607080910111213141516171819202122232425262728293031 Month of diagnosis #5MM010203040506070809101112 Year of diagnosis #5YYYY202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901190018991898189718961895189418931892189118901889188818871886 Additional Information for medical condition #5 Add medical condition Your declaration Please tick the boxes below to confirm that you understand and acknowledge the statements. I declare the information I have given is correct and complete to the best of my knowledge and belief. I confirm that I personally submitted this notice in connection with joining a workplace pension scheme. Data protection The Trustee, as the controller under the applicable data protection legislation in the UK, uses certain personal information about you to (amongst other reasons) communicate with you and administer your benefits in the Plan. Your information is shared with the Plan’s administrators, other providers of services to us, and public bodies such as HM Revenue & Customs. For more detailed information on how we use and disclose your information, the protections we apply, the legal bases we rely on and your data protection rights, please see our privacy notice at www.pearson-pensions.com/privacy-notice/ - This link opens in a new browser window. If you would like a copy of our privacy notice to be sent to you, please contact the pensions helpline. I confirm I understand that the data I provide will be used as outlined in the data protection statement. Today's Date: Date: 19-01-2026 Thank you You will receive a confirmation email shortly. Your form will be processed by the pensions team. Please contact them directly if you have any queries. Back to Home
