Annexure A
FROM:
AFCONS SUPERANNUATION FUND
AFCONS HOUSE, VEERA DESAI ROAD
16, SHAH INDUSTRIAL ESTATE,
AZAD NAGAR, ANDHERI (W) 400058
TEL 22872535 / 22821180
MASTER POLICY NO. GSCA/10586
MASTER POLICY NO. NGSCA/ 706000452
INTIMATION OF RETIREMENT/DEATH/LEAVING SERVICE
1. Name of Member
2. (a) LIC Membership Number
(b) Salary Roll No./Identity No
(C) PAN No
3. Date of Exit
4. (a) Cause of Exit
(b) In case of Death, cause of death
(Death Certificate to be attached)
5. (a) Final Contribution, if any, on
cessation of service
6. Whether Option to commute part of
Pension exercised or not? (Tick
Appropriate column)
7. If the answer is YES, what Proportion?
(Tick applicable Column)
8. Type of Pension Option elected
(Tick appropriate option)
9. Mode of annuity
TO:
LIFE INSURANCE CORPORATION OF INDIA
P&GS DEPARTMENT, MUMBAI
DIVISIONAL OFFICE,“YOGAKSHEMA”
JEEVAN BEEMA MARG,
P.B. NO. 11709, MUMABI-400021
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: ______________________________________________
: _______________________________________________
: _______________________________________________
: YES NO
: 1/3 1/2
: 1. LIFE PENSION
2. PENSION GUARANTEED FOR 5 YRS + LIFE
3. PENSION GUARANTEED FOR 10 YRS + LIFE
4. PENSION GUARANTEED FOR 15 YRS + LIFE
5. PENSION GUARANTEED FOR 20 YRS + LIFE
6. LIFE PENSION WITH RETURN OF CORPUS
7. JOINT LIFE PENSION
8. JOINT LIFE AND LAST SURVIVORS ANNUITY
WITH RETURN OF CORPUS.
: Mly / Qly / Hly / Yly
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10. In case Pension is Immediate, particulars
of Member or Beneficiary :

(i) Address :

(ii) If pension to Beneficiary, Name and

Date of Birth of the Beneficiary :

(iii) 2 Specimen Signatures of Member/

Beneficiary

(iv) Name, Address of Bank and

Account No. to which Pension is to
be credited : Account No.:

Bank:

Address:

PLACE:

DATE:

(for office use only)

For Self and Trustees of _Afcons Infrastructure Ltd

Superannuation Scheme

Signature: ____________________________________

PLACE: Mumbai
TRUSTEE
DATE:

Note : It is very important that Appropriate Answers are given specifically under Item Nos. 6,7 & 8,
without which the settlement will not be possible.

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 SECTION I
PENSION CLAIM FORM
(to be completed by Annuitant)

LIFE INSURANCE CORPORATION OF INDIA

P&GS DEPARTMENT, MUMBAI DIVISIONAL OFFICE,
“YOGAKSHEMA”
JEEVAN BEEMA MARG,
P.B. NO. 11709, MUMABI-400021

Dear Sir,

I, Shri/Smt.
opt for payment of pension for years certain and life thereafter with/without
commutation.

I request you to credit future instalments of pension directly to my type of Bank A/c
, Bank A/c No. in the Bank
Address

My Address for Correspondence

(Signature of Annuitant)
Date:

SECTION II

(to be completed by Annuitant)

I, Shri/Smt. receive from the Life

Insurance Corporation of India the sum of Rs. (Rupees
) in full satisfaction and discharge of my under mentioned claims and
demand under the Master Policy No.
Commuted Value of Pension - Rs.
Monthly/Quarterly/Half- Re.1/-
yearly/Yearly - Rs. Revenue
Stamp
Total - Rs.

Witness Signature of Annuitant

Address
Place
Date
Specimen Signature of Witness (PTO)

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 SECTION III
PENSION CLAIM FORM
(to be completed by Trustees)

LIFE INSURANCE CORPORATION OF INDIA

P&GS DEPARTMENT, MUMBAI DIVISIONAL OFFICE,
“YOGAKSHEMA”
JEEVAN BEEMA MARG,
P.B. NO. 11709, MUMABI-400021

Dear Sir,

We hereby direct, authorise and empower you to pay on our behalf to Shri/Smt.
the pension amount as per the option elected by him/her above after deduction of
Income Tax and other taxes and duties as given below.
X

Commuted Value of Pension Total Amount Less: Income Net Amount

Tax & other Payable
duties
Total Pension Instalments due

From to 31-03-
(i.e. during the current financial year)

We hereby admit and acknowledge that the abovementioned payments which shall be made by
you shall be in full settlement of the payments due to us and hereby declare that the receipts
signed by the payees shall be sufficient, valid and legal discharge to you for the respective
payments made to them and shall be fully binding upon us as if the payments have been made to
us and the receipts signed by us.

N.B. X 1) If no tax is to be deducted against above A/c, please write “NIL”.

X 2) Please specify the tax to be deducted against each head of account separately.

Signature of Trustees

Place: Mumbai Address: Afcons Infrastructure Ltd Superannuation

Date: Scheme,

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 Section IV
(To be completed by the Annuitants and witnessed by the Trustees)

NOMINATION

I ,Shri/Smt _________________________________________________________ a member of the

AFCONS Infrastructure Superannuation Scheme, hereby nominate Shri/Smt _____________________

____________________________aged _________years who is related to me as_______________,

to receive the Pension in the event of my death during the guaranteed period as per the rules of the

Scheme / the Pension Corpus on my death. I further agree and declare that upon such payment, the

Corporation will be discharged of all liability in this respect under

the Master Policy No.

____________________

Signature of Annuitant
Witness: ________________________

____________________

Signature of the Nominee

Address: ________________________

_______________________

_______________________

_______________________

Place : _______________________

Date : _______________________

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ECS MANDATE FORM

Ref: LIC/ECS Mandate / Date:

The Manager (P&GS)

LIC of India,
NEW INDIA BULG., 2ND FLR
SANTACRUZ WEST MUMBAI 400054.

Dear Sir / Madam,

1. NAME OF THE ANNUITANT and Tel no: _________________________________

Email:_________________________________

2. PARTICULARS OF BANK ACCOUNT

A. BANK NAME

B. BANK BRANCH NAME

C. BANK BRANCH ADDRESS

D. ACCOUNT TYPE (SB

ACCOUNT/CURREENT ACCOUNT
OR CASH CREDIT) WITH CODE
10/11/13
E. DIGIT MICR CODE NO.(AS
APPEARING ON CHEQUE BOOK)
F. ACCOUNT NO .(AS APPEARING
ON CHEQUE BOOK)

G. E-MAIL ADD OF ANNUITANT

I, hereby declare, that the particulars given above are correct and
complete. If the transaction is delayed or not effected at all for
reasons of incomplete or incorrect information, I would not hold LIC
responsible. I have read the option invitation letter and agree to
discharge the responsibility expected of me as a participant under the
Scheme.

Date:

Signature of Annuitant: ______________

Note: Kindly attach a blank cancelled cheque leaf or a photocopy

thereof for verification of the above particulars)

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