– Step 1 of 4

THIS FORM MUST BE COMPLETED BY THE PRINCIPAL OFFICER & MEMBER’S DEPENDENT

Name of Fund/Scheme

A) MEMBER DETAILS

Full Name *

Date Of Birth *

Marital Status: *

National identity number *

Employee Ref No :

Date of joining Fund: *

Date of death: *

Date last actively at work: *

Month of last contribution: *

DEPENDANTS’ DETAILS

Details of Dependants/Beneficiaries to receive benefit in terms of the Rules or Board of Trustees Resolution:

Spouse/s name(s)

Date Of Birth

Children Names & Date of Birth

1. Name Surname, Day.Month.Year
2. Name Surname, Day.Month.Year

Other dependants

1. Name Surname, Day.Month.Year, relationship
2. Name Surname, Day.Month.Year, relationship

If no dependants exist and payment is to be made to the deceased’s estate, please state name and address of Executor or Administrator of the deceased’s estate:

PAYMENT INSTRUCTION

(attach bank details confirmation eg copy of bank statement, bank card reflecting account number, bank letter etc)

Name of Bank / Building Society

Branch

Account Number

Contact address

Please attach the following documents in respect of this claim and mark with a tick to show those attached.

Original Certificate of Death | Proof of age of Spouse and Dependent Children (under the age of 18 or 23 years if in full time education) | Proof of marriage (where applicable) | Letters of Administration (where applicable) | Letters of Administration (where applicable) *

Click or drag files to this area to upload. You can upload up to 10 files.

NB. Proof of age must be submitted in the form of Birth Certificate, National Registration Card, Drivers Licence or Passport

Website

Notification Off Withdrawal – Step 1 of 3

THIS FORM MUST BE COMPLETED BY THE PRINCIPAL OFFICER & MEMBER’S DEPENDENT

Name of Pension Fund/Scheme

THIS FORM MUST BE COMPLETED BY THE PRINCIPAL OFFICER & MEMBER’S DEPENDENT

Title *

First name(s) *

Surname *

National identity number

Date of Birth

Employee Ref No

Date of Joining Fund

Date of Withdrawal

Month of Last Contribution

Salary as at Withdrawal Date

REASON FOR WITHDRAWAL

REASON FOR WITHDRAWAL ( tick the applicable )

Voluntary Resignation
Retrenchment
Dismissal

Refund of contributions to be ( tick the prefered option)

Paid As Cash
Transferred to other Fund
Preserved

If ‘transferred’ state name of Fund and Underwriters of the Fund

MEMBER’S CONTACT DETAILS AND PAYMENT INSTRUCTIONS

Residential/postal address

Telephone / mobile numbers

E-mail address *

Name of bank/ Building Society

Branch

Account number

Attach bank details confirmation eg copy of bank statement , bank card reflecting account number, bank letter etc

Click or drag a file to this area to upload.

Phone

– Step 1 of 4

THIS FORM MUST BE COMPLETED BY THE PRINCIPAL OFFICER & MEMBER’S DEPENDENT

Name of Fund/Scheme

A) MEMBER DETAILS

Title

Mr
Mrs
Miss

Full Name *

Date Of Birth *

Marital Status: *

National identity number *

Employee Ref No :

Date of joining Fund: *

Please attach the following documents: Member’s and spouse’s or dependent’s ceritified copy of National Registration Card / Passport/ Driver’s licence) / Certified copy of marriage certificate *

Click or drag files to this area to upload. You can upload up to 10 files.

DEPENDANTS’ DETAILS

Details of Dependants/Beneficiaries to receive benefit in terms of the Rules or Board of Trustees Resolution:

Type Of Retirement

Date of Retirement:

Month of Last Contribution:

Pensionable Salary at date of retirement

Member’s options:

Full pension without commutation OR
1 /3 Cash Commutation plus balance pension

PAYMENT INSTRUCTION

(attach bank details confirmation eg copy of bank statement, bank card reflecting account number, bank letter etc)

Name of Bank / Building Society

Branch

Account Number

Attach bank account confirmation eg copy of bank statement, bank card reflecting account number, bank letter etc *

Click or drag files to this area to upload. You can upload up to 10 files.

Address

Mobile number

E-mail address

Phone

Claims & Forms

THIS FORM MUST BE COMPLETED BY THE PRINCIPAL OFFICER & MEMBER’S DEPENDENT

A) MEMBER DETAILS

DEPENDANTS’ DETAILS

PAYMENT INSTRUCTION

THIS FORM MUST BE COMPLETED BY THE PRINCIPAL OFFICER & MEMBER’S DEPENDENT

THIS FORM MUST BE COMPLETED BY THE PRINCIPAL OFFICER & MEMBER’S DEPENDENT

REASON FOR WITHDRAWAL

MEMBER’S CONTACT DETAILS AND PAYMENT INSTRUCTIONS

THIS FORM MUST BE COMPLETED BY THE PRINCIPAL OFFICER & MEMBER’S DEPENDENT

A) MEMBER DETAILS

DEPENDANTS’ DETAILS

PAYMENT INSTRUCTION

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