Withdrawal Due To Superannuation Incapacitation
Withdrawal Due To Superannuation Incapacitation
Withdrawal Due To Superannuation Incapacitation
Select Annuity Service Provider (please tick one of the below options as per your choice)
Life Insurance Corporation of India HDFC Life Insurance Company Ltd
ICICI Prudential Life Insurance SBI Life Insurance Company Ltd
Star Union Dai-ichi Life Insurance Company Limited
Select Annuity Scheme (please tick one of the below options as per your choice)
Annuity for Life
Annuity for Life with return of purchase price on death
Annuity payable for life with 100% annuity payable to spouse on death of annuitant
Annuity payable for life with 100% annuity payable to spouse on death of annuitant with return on purchase of annuity
NPS-Family Income option (Default annuity)
Other (Please Specify)
Select Annuity Frequency: Please tick one of the below options as per your choice. (For Government Subscriber, annuity frequency is monthly only)
Monthly Quarterly Half Yearly Annual
*In case of female right thumb Impression and in case of male left thumb Impression may be taken
Section F - Subscriber’s Family Member Details* (To be filled in case subscriber has selected Joint Life Policy or NPS-Family Income option)
Family Member Details for providing annuity as chosen by the subscriber.
Sr.No Details Full Name Aadhar/VID PAN$ Date of Birth
1. Spouse$ DD / MM / YYYY
2. Dependent Mother (if living) DD / MM / YYYY
3. Dependent Father (if living) DD / MM / YYYY
4. Child 1 (if living) DD / MM / YYYY
5. Child 2 (if living) DD / MM / YYYY
6. Child 3 (if living) DD / MM / YYYY
Note: In case of children being more than 3, please specify in an additional sheet.
Fields marked with* are mandatory.
$
Mandatory in case subscriber opts for Joint Life Policy & NPS-Family Income option.
Declaration by the Subscriber
I hereby declare and state that all the personal details provided by me in the form as above are true and correct to the best of my knowledge. I also agree
that NPS Trust / CRA shall not be held responsible/liable for any losses or delays that may arise due to provision of incorrect details including details
pertaining to bank account by me. Further, I authorize the National Pension System Trust (NPST)/ CRA to share informations pertaining to my withdrawal
application with the Annuity Service Providers for facilitating the purchase of annuity in applicable cases as is required under NPS.
Declaration by the Proposer: (Not to be filled in case of complete withdrawal, Withdrawal of Deferred Lump Sum Corpus & phase withdrawal)
I hereby declare that the foregoing statements and informations have been given by me after fully understanding the questions and the annuity options and
the same are true, accurate and complete in every manner and respects and that I have not withheld or omitted to give any material information. I understand
and agree that the statements in this proposal constitute warranties. I do hereby agree and declare that these statements and this declaration shall be the
basis of the contract of assurance between me and Annuity Service Provider (Company) and that if there be any misstatement or suppression of material
information or if any untrue statement is contained therein or in case of fraud by me, which comes to the knowledge of the company at any future point of time,
the said contract shall be treated as per provisions of Section 45 of the Insurance Act 1938 or any other applicable provisions as amended from time to time.
I also understand and agree that the company shall additionally levy or recover all the applicable taxes like service tax, surcharges, cess etc. from the
premiums which are necessitated by various enactments of central and/or state legislatures from time to time.
I understand that the contract will be governed by the provisions of the Insurance Act 1938, and other applicable laws in India and that the contract will not
commence until a written acceptance of this proposal is issued by the company and that the benefits under the policy shall be subject to the terms and
conditions contained in the contract. I also agree that the amount held in proposal/policy deposit shall not earn any interest.
I further state that the product features and terms and conditions of the policy have been thoroughly explained to me and having understood, I consent to
the same.
I further understand that the final annuity amount would be subject to the actual corpus value to be utilised for purchase of annuity at the time of its issuance.
I also acknowledge and agree that the funds will not be returned to me in case I choose to cancel the policy under free look period. These funds will be
payable by company directly to any other annuity scheme chosen by me which is authorized and approved under the prevalent regulations and applicable
rules. Further, no interest will be payable to me on the funds held during this transition period.
I hereby authorize company to send information and servicing related communication regarding this proposal or resulting policy through Email/SMS/Phone
Call.
I hereby authorize the company to provide me/our details to banks, financial institutions and third party service providers that the company may have tie-ups
with, for verification of proposal details and for servicing of policies.
Place:
Date: DD / MM / YYYY
Declaration when Proposal form is filled by person other than proposer/proposer signs in a vernacular language/proposer is illiterate
(Not to be filled in case of complete withdrawal, Withdrawal of Deferred Lump Sum Corpus & phase withdrawal)
I hereby state that I have read out and explained the contents of this proposal form and all other I/We state that the product details, contents of
relevant documents to the proposer in language, he/she/they have this form and relevant documents have been
understood the same and agree to abide by the terms and conditions of the resulting policy and have fully explained to me/us and that I/We have fully
affixed his/her/their signature/thumb impression on the proposal form in my presence. understood them. I/We certify that the replies in
the proposal form have been recorded as per
the information provided by me/us.
Date D D / M M / Y Y Y Y
Date D D / M M / Y Y Y Y
[As per Regulation 3(a)/4(a)/5(a) of PFRDA (Exits and Withdrawals) under the Regulations, 2015]
(To be filled in case of complete withdrawal)
Request cum under taking form for withdrawal of total pension wealth at superannuation and where the total pension wealth is equal to or less
than Rs. 2,00,000/- for NPS subscriber and Rs. 1,00,000/- in case of NPS lite Subscriber respectively
*In case of female right thumb Impression and in case of male left thumb Impression may be taken.
Date D D / M M / Y Y Y Y
Rubber Stamp of the DDO/POP-SP/ NLCC Signature of the DDO/POP-SP/ NLCC Registration No. of DDO/POP-SP/ NLCC
Date D D / M M / Y Y Y Y