PRUMUSIKILI PENSION TRUST FUND

Managed by Prudential Pensions Management Zambia

WITHDRAWAL CLAIM FORM

1. APPLICATION FOR A BENEFIT

Having satisfied the exit conditions as provided in the Fund Rules, you will need to fill in this Form in order for you
to apply for any of the benefits payable under the LOLC Finance Pension Scheme affiliated to the Prudential
Pensions Management Zambia Limited managed Pru-Musikili Pension. The Benefits are paid in accordance with
the Trust Deeds, Scheme Rules, Income Tax Act and the Pension Scheme
Regulations Act. Carefully read through the instructions below before you start filling in this form.

2. RETIREMENT BENEFIT
In order to qualify for a retirement benefit, you should have reached the Normal Retirement Age
of 60 years. Having attained the Normal Retirement Age, you;

2.1.become entitled to a pension of such amount as per the balance accumulated in your
account under the Fund at the date of your retirement.

2.2.may elect to commute a portion of up to 50% of the amount accumulated in your account at the
date of your retirement for an equivalent cash sum. The balance shall be used to purchase a
monthly pension from an insurance company of your choice, on your behalf by the Trustees.

3. DEATH BENEFIT-
In the event that a member dies in employment, the Trustees may pay cash to or purchase an annuity
for the nominated beneficiaries equal to the balance in the member’s account at the date of his death.
This benefit is only paid to nominated beneficiaries registered by the member prior to his death

4. ILL HEATH
If you are discharged from employment on medical grounds, you qualify to claim Ill Health benefit. You may
claim this benefit by filling in a claim form and attaching a certified copy of the Medical Discharge Certificate.

5. REFUND OF CONTRIBUTIONS

If you leave employment, for whatever reason, you:

5.1.may claim the balance of what is in your account at the date of leaving employment subject to
taxes in place.
5.2.may transfer the balance in your account at the date of leaving employment to another
approved Fund.
5.3.may defer the balance in your account at the date of leaving employment
6. MEMBER DETAILS
6.1. EMPLOYER NAME

6.2. SURNAME

6.3. MIDDLE NAME

6.4. FIRST NAME

6.5. NRC NUMBER / /

6.6. DATE OF BIRTH D D / M M / Y Y Y Y

6.7. DATE JOINED FUND D D / M M / Y Y Y Y

6.8. DATE OF WITHDRAWAL D D / M M / Y Y Y Y

7. CLAIM DETAILS

7.1. REASON FOR WITHDRAWAL 7.2. REASON FOR WITHDRAWAL

Tick Tick
7.2.1. Resignation 7.2.2. Cash Refund
7.2.3. Retrenchment 7.2.4. Will Claim in Future
7.2.6 Dismissal 7.2.5. Transfer to Another Fund
7.2.7 Other termination

8. PAYMENT DETAILS

8.1. PAY MY BALANCE TO

8.1.1. Surname

8.1.2. Other Names

8.1.3. Name of Bank

8.1.4. Account Number

8.1.5. Name of Branch

9. DECLARATION
I declare that I have freely chosen from the options in (7) above and freely request the Trustees to
act as per my instruction. I also understand that The payment of this Benefit will be in full and final
settlement of all sums due to me and I shall have no further claim on the Scheme.

Signature of Member:________________ Date:___________ Contact

No:___________

10 FOR EMPLOYER USE

Employer Authorized Signatory: ________________ Date:_____________ Official Stamp