Intimation Form Dd44e4

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SCI EMPLOYEE SUPERANNUATION SCHEME

MASTER POLICY NO GSCA/706002139

TO: LIFE INSURANCE CORPORATION OF INDIA


P&GS DEPARTMENT/MDO I
YOGAKSHEMA, 4TH FLOOR, EAST WING
MUMBAI 400 021

INTIMATION OF RETIREMENT/DEATH/LEAVING SERVICE

1. Name of Member : ______________________________________________

2. (a) Pension ID : ______________________________________________

(b) EC No. : ______________________________________________

3. Date of Birth : ______________________________________________

4. Date of Exit : ______________________________________________

5. (a) Cause of Exit : ______________________________________________

(b) In case of Death, cause of death


(Death Certificate to be attached) : _______________________________________________

6 (a) Final Contribution, if any, on


Cessation of service (compulsory) : NOT APPLICABLE

7. Whether Option to commute part of


Pension exercised or not? (Tick
Appropriate column) : NOT APPLICABLE

8. If the answer is YES, what Proportion?


(Tick applicable Column) : NOT APPLICABLE

9. Type of Pension Option elected


(Tick appropriate option) :

a. Pension ceasing at death with payout of whole life assurance.


b. Pension with guaranteed payments for 10 years + Life
c. Pension with guaranteed payments for 5 years + Life
d. Pension with guaranteed payments for 15 years + Life
e. Pension with guaranteed payments for 20 years + Life
f. Joint life and last survivor pension
g. Life and 50% to last survivor
h. Joint life and last survivor pension with return on capital
i. Life pension without any guaranteed payments
j. Pension increasing at simple rate 3% p.a.

If Joint Life Pension – Name of Spouse - __________________________________


(compulsory)
Date of birth of Spouse - _____________________________

10. Mode of annuity : Mly / Qly / Hly / Yly :

11. In case Pension is Immediate, particulars


of Member or Beneficiary : _______________________________________________

(i) Your Residential Address with PIN


No, Dist.,/Taluka/State _______________________________________________

_______________________________________________
(ii) If pension to Beneficiary Name and
Date of Birth of the Beneficiary :

(iii) 2 Specimen Signatures of Member or Beneficiary :

_____________________________________________________________________________________

(iv) Name, Address of Bank and Account


No. to which Pension is to be credited: _______________________________________________

_________________________________________________
IFS Code: _____________________________________
MICR: _______________________________________

(v) Whether docket to be transferred to nearest servicing unit to your correspondence address Y / N ?
if ‘Y’ which __________________________________________

(vi) Your Telephone No (with STD Code)


& E mail ID for effective communication purpose:
(T) _________________ E mail: ______________________

For SCI Employee Superannuation Trust

Signature: _________________________

TRUSTEE

Note: Please select one of the options at point no. 9 to enable us to initiate the process of disbursement of Pension.

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