REQUEST FOR PENSION (ANNUITY) PAYOUT

Policy Number
Name of
Policyholder
Mr./Ms./Mrs. First Name Surname

Contact Nos.
STD Residence STD Office Ext. ISD Mobile

E-Mail ID

PORTION OF YOUR MATURITY AMOUNT THAT YOU WANT TO RECEIVE PENSION FROM
I wish to receive pension from 100% of my maturity amount.
I wish to withdraw _______________% of my maturity amount (maximum 33.33% of the maturity amount allowed) and utilize the balance to
receive pension.
I hereby declare that I have been assisted by the below employee (if applicable) in filling up the form

Bank:
Employee Name Business Code
Branch:

Source: 0 0 N A

PENSION OPTIONS TO RECEIVE INCOME (Choose any one)

Sr. No. Option name

1 Life Annuity without Return of Purchase Price

2 Life Annuity with Return of Purchase Price

3(a) Life Annuity with Return of 50% Purchase Price

3(b) Life Annuity with Return of 75% Purchase Price

4 Life Annuity with Return of Balance Purchase Price

5(a) Life Annuity Guaranteed for 5 years and payable for life thereafter without Return of Purchase Price

5(b) Life Annuity Guaranteed for 10 years and payable for life thereafter without Return of Purchase Price

5(c) Life Annuity Guaranteed for 15 years and payable for life thereafter without Return of Purchase Price

6 Life Annuity with Return of Purchase Price on Critical illness (CI) or Permanent Disability due to accident (PD) or Death

7 Life Annuity with annual increase of 5% without Return of Purchase Price

8 Joint Life, Last Survivor without Return of Purchase Price

9 Joint Life, Last Survivor with Return of Purchase Price

10 Joint Life, Last Survivor with Return of Purchase Price in parts

Pension payout frequency Yearly Half Yearly Quarterly Monthly

DETAILS OF NOMINEE (Applicable only if you choose option 2,3,4,5,6,9 or 10)

Name
Mr./Ms./Mrs. First Name Surname
Date of Birth D D M M Y Y Y Y Relationship with you

Current Address

City PIN Code

State Country
In case of change in address, please submit address proof. The request will be processed on receipt of relevant address proof
Contact Nos.
STD Residence STD Office Ext. ISD Mobile
If the nominee is a minor, please name an appointee
Appointee Name
Mr./Ms./Mrs. First Name Surname
Relationship of the appointee to the nominee
Current Address

City PIN Code

State Country
In case of change in address, please submit address proof. The request will be processed on receipt of relevant address proof
Contact Nos.
STD Residence STD Office Ext. ISD Mobile

Acceptance signature of the Appointee Signature of Policyholder

Details of Spouse (Applicable only if you choose option 8, 9 or 10)

Name
Mr./Ms./Mrs. First Name Surname

Date of Birth D D M M Y Y Y Y

Contact Nos.
STD Residence STD Office Ext. ISD Mobile
E-Mail ID

YOUR BANK ACCOUNT DETAILS TO RECEIVE PENSION

Name of Customer
(as mentioned in the bank account and printed on your cheque)

Name of Bank
Branch Address
Account Type Current Account Saving Account
Bank Account No.
(as printed on your cheque)
CBS
IFSC Code of Bank PERSONAL BANKING : SAVING ACCOUNT DATE ....................
PAY ................................................................................................................................................
................................................................................................................................................... OR BEARER
RUPEES ...................................................................................................
MICR Code of Bank ..................................................................................................................
Rs.
ANWB
SBGEN A/c No.
9 digit code as appearing on the Cheque copy issued by bank. 005070123756

ICICI Bank Limited

Prabhadevi Branch
Ground Floor, Kala Academy, Ravindra Natya Mandir Amit Wadekar
Prabhadevi Mumbai - 400 028
RTGS / NEFT IFSC Code : ICIC0000057

|| 338894|| 400229013|: 000000|| 31

Branch Address MICR Code IFSC Code Name

Account No.

Signature of Policyholder Place: Date: DD/MM/YYYY

SUBMIT THIS FORM WITH THE FOLLOWING DOCUMENTS:

Cancelled cheque of your bank account. Name of account holder and account number should be printed on the cheque.

Signed copy of address proof (if you have changed your registered address).

Signed copy of your PAN card.

Signed copy of age proof of spouse such as passport, driving license, PAN card etc. (if you choose joint life pension
option).

YOU CAN SUBMIT THIS FORM AND DOCUMENTS THROUGH ANY OF THESE OPTIONS:

@ Email:
Email the scanned copy of the form and documents to lifeline@iciciprulife.com.

Branch:
Submit the form and documents at any of our branches. To locate the nearest branch, visit
www.iciciprulife.com/branchlocator.

Courier: Courier the form and documents to

Pension Department, ICICI Prudential Life Insurance Co. Ltd., Unit No. 1A & 2A, Raheja Tipco Plaza, Rani Sati Marg, Malad
(East), Mumbai- 400 097.

DECLARATION
Applicable when the Proposer is illiterate or suffering from disability due to which writing is restricted or the proposer has signed in vernacular
language. Note: Must be witnessed by someone other than the advisor/agent/employee of the Company.
I (Full name of Witness) ________________________________________ (Relation with Proposer) ____________________ adult and inhabitant of (Address)
______________________________________________________________________________ do hereby declare that I have read and explained the contents of
this form to the Proposer and he/she/they have understood the same.

_________________________________
(Signature of Witness)
ICICI Prudential Life Insurance Company. IRDAI Regn No. 105. CIN:U66010MH2000PLC127837. Registered Address:- 1089 Appasaheb Marathe Marg,
Prabhadevi, Mumbai-400025. COMP/DOC/Jul/2018/47/1378.