Axis Bank Ltd-Employees Superannuation Scheme

MASTER POLICY NO GSCA/609989

Instructions and Guidelines:

1. This form should be filled up only by employees who are members of the Axis Bank Superannuation
Scheme.
2. Only employees who have joined Axis Bank before the year 2007 and are not paid “Superannuation
allowance” in their salary are members of the Superannuation Scheme. In other words; if
“Superannuation allowance” is being paid to you in your monthly salary; you are not a member of
Superannuation Scheme.
3. Superannuation Scheme, as the name suggests; is a Pension Scheme managed by LIC. Upon
Resignation; amount accumulated with LIC is used to provide Pension to the member.
4. Member of Superannuation Scheme has an option to commute one-third of the accumulated
amount. However; withdrawal of entire corpus is NOT POSSIBLE.
5. The application should be filled in Blue/Black ink and in BLOCK LETTERs.
6. Please avoid overwriting.
7. Mention your EMP ID in the extreme top right corner of all the pages.
8. Duly filled and signed 5 page form in original along with copy of cancelled cheque and date of birth
proof of Nominee should be submitted to our outsourcing partner :
PF Trust, TSR Darashaw Pvt. Ltd. 6-10, Haji Moosa Patrawala Ind. Estate, 20 Dr. E-Moses Road;
Near Famous Studio; Mahalaxmi, Mumbai 400 011.
9. You may reach us on [email protected] for queries related to status of your
Superannuation form.
I have read and agree to the above-mentioned instructions and guidelines.

(Signature)

Address for Communication

Personal Details
(with Landmark and Pin code)
Name :

Designation :

Emp No. :

Contact No. :

Personal Email ID :
(Do not mention Axis Bank email ID)

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 Axis Bank Ltd-Employees Superannuation Scheme
MASTER POLICY NO GSCA/609989
TO: LIFE INSURANCE CORPORATION OF INDIA
P&GS DEPARTMENT, YOGAKSHEMA, MUMBAI 400 021.

INTIMATION OF RETIREMENT/DEATH/LEAVING SERVICE – FORM-A

1) Name of Member :
2) (a) LIC Membership Number :
2) (b) Salary Roll No./Identity No :
3) Date of Birth :
4) Date of Exit :
5) (a) Cause of Exit :
(b) In case of Death, cause of death
(Death Certificate to be attached) : __________________________________________________________________________________
6) (a)Final Contribution, if any, on
Cessation of service : __________________________________________________________________________________
7) Whether Option to commute part of Pension
Exercised or not? (Tick Appropriate column) : YES NO
8) If the answer is YES, what Proportion?
(Tick applicable Column) : 1/3
9) Type of Pension Option elected
(Tick appropriate option)
I. PENSION GUARANTEED FOR 15 YRS + LIFE
II. PENSION GUARANTEED FOR 10 YRS + LIFE
III. PENSION GUARANTEED FOR 5 YRS + LIFE
IV. PENSION CEASING AT DEATH (WITHOUT ANY GUARANTEED
PAYMENTS)
V. OPTIONAL JOINT LIFE AND LAST SURVIVOR
(PENSION TO MEMBER AND HIS WIFE)
VI. OPTIONAL JOINT LIFE & LAST SURVIVOR PENSION WITH
RETURN OF CORPUS
VII. LIFE ANNUITY WITH RETURN OF CORPUS
If Joint Life Pension – Name of Spouse (Compulsory) ___________________________________________
Date of birth of Spouse ____________________________________________
10) Mode of annuity (Mly/Qly/Hly/Yly) : ___________________________________________________________________________________
11) In case Pension is Immediate, particulars
of Member or Beneficiary : ___________________________________________________________________________________
(i) Residential Address : ___________________________________________________________________________________

___________________________________________________________________________________
(ii) 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 : ___________________________________________________________________________________

: ___________________________________________________________________________________

(v) Mobile No and Email ID for effective

Communication purpose : ______________________________________: ____________________________________________

AXIS BANK LTD. EMPLOYEES SUPERANNUATION SCHEME

PLACE : MUMBAI
DATE : TRUSTEE

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 Axis Bank Ltd-Employees Superannuation Scheme
MASTER POLICY NO GSCA/609989

PENSION CLAIM FORM-FORM - B

SECTION I (To be completed by Annuitant)

Date :

Life Insurance Corporation of India

Mumbai Divisional Office
Yogakshema, Group Insurance Schemes Dept. (Unit 1)
Mumbai – 400 021.

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 installments of pension Directly to my Type of Bank A/c details of which are furnished
below

Bank Account Type : ________________________________

Account Number : ________________________________
Bank Name and Branch Address : ________________________________
IFSC Code : ________________________________
MICR Code : ________________________________
PAN No. : ______________________________
(Note : Please enclose photocopy of PAN card)

My address for Correspondence

________________________________
________________________________
________________________________
________________________________
(Signature of Annuitant)
Copy of Cancelled cheque to be enclosed along with the form
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
SECTION II
(To be completed by Annuitant)

I, Shri/Smt.________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. ______________________.
Commuted value of ___________________ Rs. ___________________________
Yly/ H.Yly/ Qly/ Mly installment pension due Rs. ___________________________
Total Rs. ___________________________

Witness __________________ Please sign

across
Address __________________ Revenue
Stamp of Re.
Place _____________________ 1/-

Date ______________________ Signature of Annuitant

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 Axis Bank Ltd-Employees Superannuation Scheme
MASTER POLICY NO GSCA/609989
SECTION III – FORM C
(To be completed by Trustees)

Life Insurance Corporation of India,

P&GS Department, Mumbai Div I,
4th Floor, East Wing, “Yogakshema Building”
Mumbai – 400 021

Dear Sir,
We hereby direct, authorize 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 of Rs. _________________

Total Pension Installments due ___________to ____________ (i.e. during the current financial year)
TOTAL AMOUNT (Rs.) Less Income Tax & Other Duties Net Amount Payable
(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: MUMBAI
Date : ________________
Address:
AXIS BANK LTD. EMPLOYEES SUPERANNUATION SCHEME
Axis Bank Ltd, HR Department, 11th Floor, Corporate Park, _______________________________
Behind Swastik Chambers, Sion-Trombay Road, Signature of Trustees
Mumbai - 400 071
----------------------------------------------------------------------------------------------------------------------------- -----------------------
SECTION IV – NOMINATION
(To be completed by the Annuitants and witnessed by the Trustees)

I, Shri/Smt_________a member of the Axis Bank Ltd. 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. GS (CA) 609989.

________________________ ______________________________
Signature of Trustee Signature of Annuitant

Place : MUMBAI
_____________________________
Date : _______________________ Signature of the Nominee

Copy of date of birth proof of Nominee should be enclosed along with the form.

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