Sample Form

TATA CONSULTANCY SERVICES EMPLOYEES’SUPERANNUATION SCHEME

MASTER POLICY NO GSCA/ 692068/ 706001776

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 : Your Name

2. (a) LIC Membership Number : Leave it Blank

(b) Salary Roll No./Identity No : Your Employee No

3. Date of Birth : Your Date of Birth

4. Date of Exit : Your Date of Release from TCS

5. : Mention Reason for Exit.(Eg: Resignation/Retirement/Death)

(a) Cause of Exit

(b) In case of Death, cause of death

(Death Certificate to be attached) : N.A
6 (a) Final Contribution, if any, on
cessation of service (compulsory) : Leave it Blank

7. Whether Option to commute part of

Pension exercised or not? (Tick
Appropriate column) : YES NO

Note for point no 7: As per the TCS Superannuation policy, you are eligible to withdraw 1/3 of SA corpus if
you are entitled for Gratuity in TCS. You will be eligible to withdraw ½ of SA corpus if you are not entitled
for Gratuity in TCS.
Tick “Yes” to withdraw the Amount partially, LIC will pay annuity (Pension) out of the remaining amount.
Tick “No” if you wish to avail the annuity (Pension) out of your full Superannuation accumulation.

8. If the answer is YES, what Proportion?

(Tick applicable Column) : 1/3 1/2 (Date of Joining if 1/2)

Your Date of Joining TCS

[Note for point no 8: Please refer note for point no 7 above.]
9. Type of Pension Option elected
(Tick appropriate option) :
 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 capital
7. Joint life pension with 100% of annuity payable to spouse on death of annuitant

[Note for point no 9: You may select any of the below mentioned Pension Plan which suites you the best.
1. Life Pension: Annuity payable only to annuitant (member) for life.

2. Pension guaranteed for 5 year’s + Life : Annuity payable to annuitant (member) for 5 years, whether or
not he/she survives that period. If annuitant dies before 5 years, annuity is payable to his/her nominee for
remaining period upto 5 years. After 5 years, if the annuitant survives, the annuity is payable to the annuitant
as long as he/she is alive.

3. Pension guaranteed for 10 years + Life : Annuity payable to annuitant (member) for 10 years, whether or
not he/she survives that period. If annuitant dies before 10 years, annuity is payable to his/her nominee for
remaining period upto 10 years. After 10 years, if the annuitant survives, the annuity is payable to the
annuitant as long as he/she is alive.

4. Pension guaranteed for 15 years + Life: Annuity payable to annuitant (member) for 15 years, whether or
not he/she survives that period. If annuitant dies before 15 years, annuity is payable to his/her nominee for
remaining period upto 15 years. After 15 years, if the annuitant survives, the annuity is payable to the
annuitant as long as he/she is alive.

5. Pension guaranteed for 20 years + Life: Annuity payable to annuitant (member) for 20 years, whether or
not he/she survives that period. If annuitant dies before 20 years, annuity is payable to his/her nominee for
remaining period upto 20 years. After 20 years, if the annuitant survives, the annuity is payable to the
annuitant as long as he/she is alive.

6. Life Pension with Return of Capital: Annuity payable to annuitant (member) for life and corpus is
refunded to nominee after death of annuitant.

7. Joint life pension with 100% of annuity payable to spouse on death of annuitant: Annuity payable to
annuitant (member) for life. On death of the annuitant, 100% of the annuity is payable to the nominated
spouse as long as the spouse is alive.

If Joint Life Pension – Name of Spouse - Your Spouse Name (compulsory for point # 7)

Date of birth of Spouse - Your Spouse Date of Birth

10. Mode of annuity: Mly / Qly / Hly / Yly - Select the mode of pension
11. In case Pension is Immediate, particulars
of Member or Beneficiary : Name of the Member

(i) Your Residential Address with PIN

No, Dist.,/Taluka/State : Your Indian Address for correspondence

(ii) If pension to Beneficiary Name and

Date of Birth of the Beneficiary : Name and Date of Birth of Nominee

(iii) Specimen Signatures of Member & Beneficiary : _

Sign of MEMBER Sign of MEMBER Sign of NOMINEE Sign of NOMINEE (Beneficary)

(iv) Name, Address of Bank and Account

No. to which Pension is to be credited: Bank Name, Address with PINCODE and A/C No of the
MEMBER

(v) Whether docket to be transferred to nearest servicing unit to your correspondence address Y / N?
if ‘Y’ which : Please mention to which nearest servicing unit of LIC Office you want your Docket to get
transferred with Full Address

(vi) Your Telephone No (with STD Code)

& E mail ID for effective communication
purpose: (T) Mandatory Email: Mandatory_ ______

For Self and Co Trustees of Superannuation Scheme

Signature:
TRUSTEE
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
 Established by the Life Insurance Corporation Act,1956
Bombay Divisional Office, Group & Superannuation Department

PENSION CLAIM FORM

SECTION I

To be completed by Annuitant

To
Life Insurance Corporation of India,
P&GS Department, 4th Floor, East Wing,
“ Yogakshema”, J.B. Marg

Mumbai – 400 021

I, Shri / Smt. Name of Member opt for payment of Pension for Leave it Blank years
certain and life thereafter / Only Life/ROC, with/without commutation.

I request you to credit future Instalment of Pension directly to my Type of Bank A/c SAVINGS
Bank A/c No Your A/c NUMBER in the Bank Your Bank Name Address:
Your Bank Address with PIN CODE

IFSCode: Your Bank IFSC Code PAN No. : Your PAN CARD Number
(Note: Please enclose photocopy of PAN card & cancelled Cheque leaflet, compulsory)

My Address for Correspondence

INDIA ADDRESS FOR CORRESPONDENCE with PIN CODE.

Your Signature

(Signature of Annuitant)
Date:
 SECTION II

(To be completed by Annuitant)

I, Shri/Smt. Your Name received 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. GSCA/

Commuted Value Rs.

Yly/ H.Yly/ Qly/ Mly Instalment pension due Rs. /-

Total Rs. /-

Need to Affix 1 Rupee Revenue Stamp.

Your Signature
Witness: (Signature of Annuitant)
Address:
Place & Date
 SECTION III

To be completed by Trustees

Life Insurance Corporation of India, P&GS

Department, 4th Floor, East Wing,
“Yogakshema”, J.B. Marg,

Mumbai – 400 022

Dear Sir,

We hereby direct, authorise and empower you to pay on our behalf to Shri / Smt _the Pension amount as per
option elected by him/her above after deduction of Income Tax and other Taxes and duties as given below:

Commuted Value (C.V.) of Rs.

Total Pension Instalments due __to (i.e during the current financial year)
TOTAL AMOUNT (Rs.) Less Income Tax & Other Net Amount Payable
Duties (Rs.) (Rs.)

(C. V.) – I Tax slab %

compulsory, if any

(Pension) – I Tax slab %

compulsory, if any

PAN No. & photo-state copy of PAN card (compulsory)

We hereby admit and acknowledge that the above mentioned 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. 1) If NO TAX is to be deducted against any above A/c, please write “ NIL” 2) Please
specify the tax to be deducted against each head of account separately.

Place:
(Signature of Trustees)
Date: Address:
 Section IV

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

NOMINATION

I, S h r i /Smt Name of Member a member of the Tata Consult ancy Services Member’ s Superannuation
Scheme, hereby nominate(s)

(1) Shri/Smt Nominee’ s Name aged Age of Nominee yrs, relation Relation with Member share
Percentage of Share (2) Shri/Smt Nominee’ s Name aged Age of Nominee yrs, relation Relation
with Member share Percentage of Share

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. GS (CA)

(If the Nominee is minor, name & address of natural guardian is obligatory)

Name & Address of Natural guardian

Mandatory: If Nominee is a Minor Mention the Indian Permanent Address of Natural Guardian

Your Signature
Signature of Annuitant

Witness: Nominee Signature / Guardian Signature if Nominee is

Minor
Address: Signature of the Nominee

Place :

Date :
 LIFE INSURANCE CORPORATION
OF INDIA P & GS DEPT, MUMBAI D.O.1
YOGAKSHEMA 1st FLOOR
EAST WING J B MARG
MUMBAI 400021.
Tel 66599107/08: email-id [email protected]. --------------------------------------------------
---------------- NATIONAL ELECTRONIC FUNDS TRANSFER – MANDATE FORM

TO
LIC OF INDIA
P&GS UNIT – G706 MUMBAI

SUB; RECEIPT OF POLICY PAYEMENT THROUGH ECS/NEFT

I am giving below the details of my company/bank account for receiving Master policy payment through
ECS/NEFT.
(1) Master policy no. / Annuity no. : Leave it Blank
(2) Type of scheme GI/GGCA/GSCA/ VRS/ IMAN/ EPS. : GSCA
(3) Name of policy holder/claimant: Your Name
(4) Bank Name: Mention your Bank Name
(5) Bank’s branch name: Mention your Bank Branch Name
(6) Account Type : Saving/Current/Cash Credit/NRI: Mention your Type of Bank A/C
(7) Account no. : Mention your Bank A/C No

(Bank account number should be written from left to right)

(8) IFSC Code: Mention your Bank A/C IFSC Code No

(9) Mobile Number +91 Mention your Mobile No

(10) E-mail id : Mention your E-mail ID
(11) Are you willing to receive SMS/E-mail on matters related to your LIC polices: Tick Your Option
Yes No
(12) PAN No: Mention your PAN No

I have enclosed the following document to this effect. (Please X appropriate item)
A. Cancelled cheque leaf
B. If cheque is not having the name of the bank holder then photo copy of the page of Bank pass
book containing details of Bank accounts number, IFS Code. Your Signature

(Signature of the Master/ Policy holder) Date: ____________

(In case of change in Bank details, please fill this mandate form again and submit the same to our
Branch office)
If your answer to Q no.9 is “Yes’ Then we will be able to send you a message when LIC transfers
money to our Account through ECS/NEFT. This message will contain the UTR which can be used
to make any enquiry regarding the payment.