SHREE CEMENT LTD.

SUPERANNUATION SCHEME
MASTER POLICY NO. GS/48173

Life Insurance Corporation of India,

P & GS Unit,
Ranadey Marg,
AJMER - 305 001.

INTIMATION OF RETIREMENT/DEATH/LEAVING SERVICE

1. Name of Member : _______________________________________________

2. Employee Code No. : _______________________________________________

3. Date of Joining the Scheme : _______________________________________________

4. Date of Exit : _______________________________________________

(a) Cause of Exit :
(b) In case of Death :
(Attach Death Certificate)

5. Final Contribution, if any, : Rs. ________________________________________

on cessation of service : Paid on ________________________________________

6. Whether option to commute

part of pension exercised : Yes
or not ? If yes What
proportion ? : Commutation of Annuity @ 1/2,1/3

7. Type of Pension option Elected : a) Annuity for certain 5/10/15/20 years and till life.
b) Life Annuity/Joint Life/Last Survivor with/without
return of capital with group pension terminal bonus.

Whether immediate or deferred pension : Immediate

8. Total withdrawal of Funds : Yes/No

*(See Note)

9. In case pension is immediate : _______________________________________________

particulars of Member or beneficiary
i) Address : ______________________________________________
______________________________________________
______________________________________________

ii) Name, Address of Bank & Account No. : ______________________________________________

to which Pension is to be credited ______________________________________________

iii) Specimen Signatures- Member : 1. _____________________ 2. _____________________

10) (i) Name of Nominee, : Name:

Date of birth of the Nominee : Date of Birth :

(ii) Specimen Signature- Nominee : 1. _____________________ 2. _____________________

11. Pension Payment Mode : Monthly/ Quarterly/Half-Yearly/Annually

 ANNUITY CLAIM FORM
(To be completed by the annuitant)

SECTION - I

Life Insurance Corporation of India,

P & GS Unit,
Ranadey Marg,
AJMER - 305 001.

I,__________________________ opt for payment of pension for years certain and life annuity
thereafter with/without commutation and return of capital.

I request you to credit future instalments of pension directly to my bank account no. __ _____
in the Bank ___________________________________ (mention name and address of your bank )

Address for correspondence :

Signature of Annuitant
over Revenue Stamp

----------------------------------------------------------------------------------------------------------------------------------
SECTION - II

I, from the Life Insurance Corporation of India a sum of Rs.____________ (Rupees

_____________________________________) in full satisfaction and discharge of my under-mentioned
claim and demand under the master Policy no. GS 48173.

Commuted Value in Full Rs.______________

Total Rs.______________

______________________
Signature of Annuitant
over Revenue Stamp

Address for Correspondence:

Signature of witness_________________________________
Name : _________________________________
Address :_________________________________
_________________________________
_________________________________
_________________________________

Note: 1. Please attach 3 financial years Salary Certificates, immediately preceding your date of exit
or total period of Service which ever is less alongwith copy of PAN no.
2. In case of withdrawl of superannuation, col. No. 1-4 and 8 on page no.1 & section II are to be
filled only.
 Annexure - 3
NATIONAL ELECTRONIC FUND TRANSFER APPLICATION FORM

To
Sr. Branch Manager (P&GS Unit)
LIC OF INDIA,
Divisional Office,
Ranadey Marg, Alwar Gate,
Ajmer(Raj.) 305001

Sub : Mandate for Electronic Mode

Sir,

I/We give below the details required for payment through Electronic Mode(Please √ appropriate item).

(1) Master Policy No. /Annuity No. __________________________________

(2) Name of MPH/ Annuitant/Beneficiary: _____________________________

(3) Bank Name: ______________________________________________________

(4) Bank Address: ____________________________________________________

___________________________________________________________________

(5) Account Type : Savings/Current _______________________________________

(6) Account No.

(7) IFS Code of The Bank:

(8) MICR Code of The Bank

(9) Contact Mobile / Landline No.

+ 9 1

(10) E-Mail Id : _______________________________________________________

Kindly transfer amount due under the above Policy/ Annuity.

The following document are enclosed as required. (Please √ appropriate item)

A. Cancelled cheque leaf

B. Photo copy of the first page of Bank pass book containing details
(if cheque is not having the name of account holder)

____________________
Signature Date :

FOR OFFICE USE ONLY

1. Name & SR No. of the person Entering the data:
2. Date of Entry :
3. Name & SR No of person Validating :
4. Date of Validation :
5. Mandate Number :