TATA CONSULTANCY SERVICES EMPLOYEES’ SUPERANNUATION FUND

MASTER POLICY NO. GSCA/ 692068

TO: LIFE INSURANCE CORPORATION OF INDIA

P&GS DEPARTM`ENT/MDO I
YOGAKSHEMA, 1ST FLOOR, EAST WING,
MUMBAI - 400021.

INTIMATION OF RETIREMENT/DEATH/LEAVING SERVICE

1. Name of Member : _____________________________________________

2. (a) LIC Membership Number : ______________________________________________

(b) Salary Roll No. /Identity No : ______________________________________________

(c) Pan card no. : _____________________________________________

(Note: Please enclose Photo copy of PAN Card)

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 1/2

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. LIFE PENSION WITH RETURN OF CORPUS
6. JOINT LIFE PENSION

10. Mode of annuity : Half Yearly / Yearly

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11. In case Pension is Immediate, particulars
Of Member or Beneficiary : _______________________________________________

(i) Name & Address _______________________________________________

_______________________________________________

_______________________________________________

(ii) If pension to Beneficiary Name and

Date of Birth of the Beneficiary :

(iii) 2 Specimen Signatures of

Member & Beneficiary : ____________________________________________
(Member) (Member)

_____________________________________________
(Beneficiary) (Beneficiary)

(iv) Name, Address of Bank and Account no.

to which Pension is to be credited:
_____________________________________________

_____________________________________________

____________________________________________

For Self and Co Trustees of Tata Consultancy Services Employees’ Superannuation Fund

Signature: ____________________________________

TRUSTEE

Note: It is very important that Appropriate Answers are given specifically

under Item Nos. 7, 8 & 9 without which the settlement will not be possible.

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 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 – 400 022

I, Shri / Smt. _______________________________opt for payment of Pension for_

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_________________Bank A/c No ______________________________ in the Bank
____________________________________Address______________________________________
_______________________________________________________________________________________
MICR NO. (9 – DIGIT CODE): ______________________________ (Mandatory)

IFSC Code: ________________________________

(Note: Please enclose Xerox copy of Cheque leaflet) (Mandatory)

My Address for Correspondence: (Please note the address need to be the address in India postal code
mandatory)

Contact / Mobile No. Email id:

(Signature of Annuitant)
Date: _______________

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. GSCA/
692068

Commuted Value Rs. ___ _________

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

Total Rs. /- Revenue Stamp

Of Rs. 1/-
Witness: ________________________________ (Signature of Annuitant)
Address: ________________________________
Place & Date________________________________

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 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.)

(Pension)

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
(Signature of Trustees)
Date:
Address: Tata Consultancy Services Employees’
Superannuation Fund
11, Air India Building, Nariman Point,
Mumbai – 400 021.

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 Section IV

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

NOMINATION

I, Shri/Smt _____________________________________________________ a member of Tata

Consultancy Services Employees’ Superannuation Fund, 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) 692068.

____________________

Signature of Annuitant
Witness: _______________________

Address: _______________________
____________________
Place : _______________________
Signature of the Nominee
Date : ________________________

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 ECS MANDATE FORM
To

The Manager (P&GS)

LIC of India, New India Bldg.,
2nd Floor, S V Road, Santa Cruz (W),
Mumbai 400 054.

Dear Sir / Madam,

1. ANNUITANT’S NAME _____________________________________________

2. ANNUITY NO ______________________________________________

3. PARTICULARS OF BANK ACCOUNT :

A Bank name
B Branch name

C ADDRESS (pin code

mandatory)

D Account type (s b account /

current account or cash
credit) with code 10/11/13
E Ledger no/ ledger folio

F Account no (as appearing on

the cheque book)

4. Date of effect __________________________________________________

I, hereby declare, that the particulars given above are correct and complete. If the transaction is
delayed or not effected at all for reasons of incomplete or incorrect information, I would not hold
LIC responsible. I have read the option invitation letter and agreed to discharge the responsibility
expected of me as a participant under the Scheme.

Date: (…………………………………)
Signature of Annuitant
CERTIFICATE OF THE ANNUITANT’S BANK

Certified that the particulars furnished above are correct as per our records.

Bank’s Stamp: (…………………………………)

Date : Signature of the Authorised Official
Of the Bank

(Note: In lieu of the Bank Certificate to be obtained as above, Annuitant can attach a blank
cancelled
cheque leaf or a photocopy thereof)

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 SA FILLING FORM GUIDELINES

Superannuation Fund is managed by Life Insurance Corporation of India (LIC).

We would request you to fill in the details and send the hard copy at the address mentioned below.

Point no 1. Mention your name

Point no 2. (a) Leave it blank.

(b) Mention your Employee number.
(c) Pan card copy is mandatory

Point no 3. Your date of birth

Point no 4. Date of Exit

Point no 5. (a) -Reason for Leaving the Company

(b) Leave it blank

Point no 6. Leave it blank.

Point no 7.
As per the superannuation policy of TCS, a member has an option to withdraw part of Corpus from
the fund; else can choose to avail the annuity pension from the entire Corpus.
Tick “Yes” if you are willing to withdraw / commute part of your superannuation accumulation else
tick “No”.

Point No 8:

If you select “Yes” at point number 7, you are required to tick on the appropriate option as
1/3 or 1/ 2 based on the following.
If the member has completed 5 or more years of TCS service i.e. who is eligible for gratuity, one third
of accumulation can be withdrawn / commuted and if the service is less than 5 years a member can
withdraw half of the total superannuation accumulation.

Please note that if you are exercising the option of withdrawal / commutation the commuted amount
would be subject to Income Tax deduction. This amount is tax exempt in case it is exercised on
retirement or death.

Point No. 9:
Tick the “Type of Pension scheme” you would like to select to get the pension (annuity). The details
of each type of pension scheme are as given below.

1) Life Pension:
In this scheme, the member will get the pension for lifetime. No pension will be paid to the
beneficiary after demise of the member. The pension amount payable under this option is
higher than all other schemes mentioned below.

2) Pension Guaranteed for 5 years + Life:

In this scheme, the member will get the pension for lifetime. For the first five years the
pension is guaranteed. For e.g. Pension has been started for the member and if member’s
demise occurs after two years from the commencement of such pension, under the said
circumstances, the beneficiary will get the pension for next three years. No further pension
will be paid to the beneficiary after completion of three years. However, if the member is
alive post completion of five years from the commencement of pension, he/she will continue
to get the pension till lifetime.

Please Note:
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 The pension will not be paid to the beneficiary if the member’s demise occurs after five
years from the commencement of pension.

3) Pension Guaranteed for 10 years + Life:

In this scheme, similar to option above 2, the pension is guaranteed for 10 years. All other
situations will be similar to option 2.

4) Pension Guaranteed for 15 years + Life:

In this scheme, similar to option 2, the pension is guaranteed for 15 years. All other situations
will be similar to above option 2.

5) Life Pension with Return of Corpus:

In this scheme, the member will get the pension for lifetime. Post member’s demise, the
beneficiary will get the corpus amount from LIC.

Please Note:
No pension will be paid to the beneficiary after the demise of the member.

6) Joint Life Pension:

In this scheme, the member will get the pension for lifetime. Post member’s demise,
member’s spouse will get the pension till his/her lifetime.

Point No.10: You have the option to choose the annuity cycle of Half Yearly or Yearly, your annuity
cycle will be based on the option selected.

Point No. 11:

(i) You are required to fill your permanent address in India. LIC of India will record this
address for all future communication related to your annuity.
(ii) This field is required to be filled only if you are selecting any of the options from 2 to
6 under point no. 9 (Type of Pension). You are required to write the name of your
beneficiary and the beneficiary’s date of birth here. If you select option 1 i.e. “Life
Pension”, you are not required to provide beneficiary details.
(iii) Two signatures of the member and the beneficiary (if applicable) are mandatory. The
beneficiary and the nominee mentioned in Section IV should be the same.
(iv) You are required to mention the name of the Bank, Address of the branch and the
Bank Account Number to which your pension is to be credited by LIC.

Section I:

The type of pension selected at point number 9 is to be mentioned in this section along with the
complete bank details like the account number, name of the Bank, Address of the branch, MICR
Code, IFSC Code.

A photocopy of Cheque leaf and PAN card is required to be submitted along with this Form.
Furnish your communication address in India with Telephone number and Email id.

Section II:

This section is relevant only if you are willing to exercise the option of withdrawal / commutation.
You are required to sign at the place of “signature of annuitant”

Section III:
Keep it blank. (To be filled by TRUST).

Section IV:

You are required to fill in the name and age of your nominee. It also needs to be signed by you and
the nominee specified therein.

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ECS FORM:

ECS Form is required so that the Pension amount can be directly credited to your Bank Account

1) Mention your full name.

2) Annuity No would be filled by LIC.
3) A. Bank Name:
B. Name of the branch in which you are holding an account
C. Address of the branch
D. Type of account. Saving / Current (Except NRE Account).
E. Leave it blank.
F. Mention you bank account number.

4) Date of effect: Leave it blank.

Certificate of the Annuitant’s Bank is mandatory if you are submitting a photocopy of a blank
cancelled cheque leaf which does not contain your printed name on the same.
For any queries regarding your Superannuation settlement you can call us at 67791876/91877 or you
can mail at retiral.settlements@tcs.com we would be glad to assist you.

Thanks & Regards,

Retiral Settlement team,
Tata Consultancy Services Ltd.
Akruti Business Port Desk No. 4C 29 & 4C 24
4th Floor, Road No.13, MIDC,
Andheri (East). Mumbai – 400093.
Maharashtra, India.

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