8/2/2019 Claim Form - Fund _06062011__V3
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SBI Life Insurance Co. Ltd. GOPS/Claim form - Fund V1.3 6th June
2011
Scheme Type : Gratuit y/ Leave Encashment/ Superannuation/
Kalyan ULI P
Name of the Master Policy Holder :
__________________________________________
Master Policy No. :
__________________________________________
I .Comm on details (w heth er th e Scheme is Grat uit y, Leave
Encashment, Superannu ation or Kalyan ULI P)Name of t he Empl
oyee(As in the data sent to us)
Mr./ Mrs./ Ms.
Emp. Code/ Member I d.
Date of Birt h: dd / mm / yyyy
Date of Joining Servi ce: dd / mm / yyyy
Date of Exit : dd / mm/ yyyy
Mode of Exit : Retirement Resignation
Death Others
Mandatory Documents t obe att ached in case theclaim is due to
Death
1. Death Certificate issued by Municipality/Nagar Parishad
GramPanchayat(Original/ Copy Attested by Trustee/ Employer)
I I . I n case of Gratuity
Mont hly Salary: Asdefined in Grat uit y Rules
Rs. ________________
Eligibl e Period of servi cefor Gratuit y :
________Years________Months_______Days
Gratuit y benefit payable : Rs. ____________________
I n case of Kalyan ULI P:Withdrawal % age(subject t o
availability ofbalance in Fund and i fopted for) [refer
instructionspoint no. 6]
Type of SBI Life Fund Withdrawal % age
Group Balanced Plus Fund
Group Debt Plus Fund
Group Growth Plus Fund
Group Short Term Plus Fund
T O T A L > > 100.00 %
I I I . I n case of Leave Encashment
No. of days leave eligiblefor encashment:
(I n days) _____________
Eligibl e leave salary: Rs. _______ ___ per day / Rs. _______
___ per mont h
Total leave encashmentbenefit payable:
Rs. ________ __
Claim I ntim ation Form
8/2/2019 Claim Form - Fund _06062011__V3
2/2
SBI Life Insurance Co. Ltd. GOPS/Claim form - Fund V1.3 6th June
2011
Advance Discharge Voucher:
We the Trustees/Authorised Signatory/ies of
____________________________ hereby give a validDischarge in
acknowledgement of receipt of Claim moneys in respect of the above
claim as detailedbelow.
1. Gratuity / SA / Leave Encashment Amount :
Rs.________________2. Life Cover (to be filled by SBI Life) :
Rs.________________
3. Others (please specify) : Rs.________________T O T A L :
Rs.________________
I V. I n Case of Superannuat ion
Benefit Details :Benefit Amount :- RS____________
Commutation Opted YES No If Yes Commuted Value :
1/3 (in case no Gratuity is payable)[ Note : Annuity Form to be
filled incase annuity to be purchased from SBI Life]
V. Direct Fund Transfer Det ails
Name Of The Bank
Bank Account No.
Bank Branch Name
Bank Branch Code
Natur e of Account Savings Current
RTGS Code
I FSC Code
I/We hereby declare that the information provided above is true
to the best of my/our knowledge.
__ __ __ __ __ __ ____ __ __ __Authorised Signatory/ Signat ure
of Trustees
Authori sed Signator y/ Signat ur e of Tru st ees
Name of the signatory:
Seal of the Company / Trust : Place :- Date:-
Instructions:1. All fields are mandatory .2. The Claim Form
should be sent t o the below address
Mr. G ThennarasuSr. Manager- Group Operation s Depart mentSBI
Life I nsurance Company Ltd
1st Floor, Kapas BhavanPlot No.3A, Sector 10, CBD Belapur, Navi
Mumbai- 400 614
3) The claim cheque would be dispatched to your address, as per
our records 4) For any assistance please contact at 022-6645 6000
oremail to [email protected] 5) SBI Life Insurance Company
shall be discharged of all liabilities in relation to the above
claim upon receiptof claim amount by the payee mentioned above. 6)
Deunitisation will be done as per the existing allocation
percentage. 7) Claim Form before3 pm will get the same day NAV and
submitted post 3 pm will get next working days NAV.
Seal of
Trust
Please affixRe. 1/ -
revenuestamp & sign
across
