Gratuity Claim Form

Gratuity Cum Term Insurance Claim Form (GTICF)
Nø¸àWå¡[Ú[i¡ t¡=à ë³Úàƒã [¤³à ƒà[¤ ó¡³¢ ([\[i¡"àÒü[Î&ó¡)
š[º[ι [¤¤¹o
Policy Details
Name of Scheme
šøA¡ì¿¹ >à³
Name of Master Policyholder
³àС๠š[º[Î ‹à¹ìA¡¹ >à³
Member Policy Number
Master Policy Number
³àС๠š[º[Î >´¬¹
΃ìθ¹ š[º[Î >´¬¹
Member Details
΃ìθ¹ [¤¤¹o
Name of Member
΃ìθ¹ >à³
Employee Code
S/D/W of
A¡³¢W¡à¹ã ìA¡àl¡
[št¡à/Ѭà³ã¹ >à³
Date of Birth
Date of Joining
\@µ t¡à[¹J
ì™àKƒàì>¹ t¡à[¹J
Grade
ëNøl¡
Designation
Last Date of Service
šƒ
W¡àA¡[¹ìt¡ ¤Òຠ=àA¡à¹ ëÅÈ t¡à[¹J
Normal Retirement Date (Mandatory for Death Gratuity Claim)
Ѭ஡à[¤A¡ ®¡àì¤ "¤Î¹ NøÒìo¹ t¡à[¹J (³õt塸 Nø¸àWå¡[Ú[i¡ ƒà[¤¹ ëÛ¡ìy ¤à‹¸t¡à³èºA¡)
Claims Details
ƒà[¤¹ [¤¤¹o
Please mention appropriate reason of Claim -
">åNøÒ A¡ì¹ ƒà[¤¹ ™=à™= A¡à¹o l¡üìÀJ A¡¹ç¡>Resignation
Retirement
"¤Î¹ NøÒo
šƒt¡¸àK
Termination
Death
PTD
Others
¤¹JàÑz
³õt塸
[š[i¡[l¡
">¸à>¸
Please specify the following in case the reason of Claim is Death of the Member
™[ƒ ΃ìθ¹ ³õt塸 A¡à¹ìo ƒà[¤ A¡¹à ÒÚ t¡àÒìº ">åNøÒ A¡ì¹ [>³¥[º[Jt¡P¡[º l¡üìÀJ A¡¹ç¡>Date of Death
³õt塸¹ t¡à[¹J
Cause of Death
³õt塸¹ A¡à¹o
Place of Death
³õt塸¹ Ñ‚à>
Date & Time of Accident (For Accidental Death)
ƒåQ¢i¡>๠t¡à[¹J &¤} Î³Ú (ƒåQ¢i¡>àÚ ³õt塸¹ \>¸)
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ÊšõË¡à 1@4
Place of Accident
ƒåQ¢i¡>๠тà>
A Joint Venture between Dabur and Aviva
Registered Office: 2nd Floor Prakashdeep Building, 7 Tolstoy Marg New Delhi 110001 India
l¡à¤¹ &¤} "[®¡®¡à¹ &A¡[i¡ ì™ï= l¡ü샸àK [>¤[Þê¡t¡ A¡à™¢àºÚ: 2Ú t¡º, šøA¡àŃ㚠[¤[Á¡}, 7 t¡ºÑzÚ ³àK¢
[>l¡ü [ƒ[À-110001 Òü[“¡Úà
Claims/GTICF/Ver1.1/01stDec11
Gratuity Cum Term Insurance Claim Form (GTICF)
Nø¸àWå¡[Ú[i¡ t¡=à ë³Úàƒã [¤³à ƒà[¤ ó¡³¢ ([\[i¡"àÒü[Î&ó¡)
Computation of Gratuity Benefit* Nø¸àWå¡[Ú[i¡
Salary Defined as per Trust Deed - Last Drawn Monthly Basic Salary
"[á ƒ[ºº ">å™àÚã [>[ƒ¢Ê¡ ë¤t¡> - ëÅÈ KõÒãt¡ ³à[ÎA¡ ³èº ë¤t¡>
Îå[¤‹à ºà쮡¹ Ko>à*
Last Drawn Monthly Gross Salary
ëÅÈ KõÒãt¡ ³à[ÎA¡ ì³ài¡ ë¤t¡>
Gratuity Benefit Criteria - Capped / Uncapped -
If Capped, Please specify limit -
Nø¸àWå¡[Ú[i¡ Îå[¤‹à ºà쮡¹ >ã[t¡-$‹Œ¢Îã³à ™åv¡û¡ / $‹Œ¢Îã³à [¤Òã>-
™[ƒ $‹Œ¢Îã³à ™åv¡û¡ ÒÚ, ">åNøÒ A¡¹à Îã³à l¡üìÀJ A¡¹ç¡>-
Gratuity Factor to be applied
Salary Amount for computation of Gratuity (Rs)
Nø¸àWå¡[Ú[i¡¹ ëÛ¡ìy šø™åv¡û¡ [¤ì¤W¡¸ [¤ÈÚ
Nø¸àWå¡[Ú[i¡ Ko>à A¡¹à¹ \>¸ ë¤t¡ì>¹ š[¹³ào (Rs)
Total Service Period rendered by Member from Date of joining to Last date of Service (Year)
W¡àA¡[¹ìt¡ ì™àKƒàì>¹ t¡à[¹J ë=ìA¡ W¡àA¡[¹ìt¡ ¤Òຠ=àA¡à¹ ëÅÈ t¡à[¹J "¤[‹ ΃θ ì³ài¡ ë™ Î³ÚA¡à캹 \>¸ W¡àA¡[¹ìt¡ [>™åv¡û¡ [áìº> (¤á¹)
Accrued Gratuity Payable from fund
Sum Assured (For Death)
t¡Ò[¤º ë=ìA¡ šøìƒÚ \³àAõ¡t¡ Nø¸àWå¡[Ú[i¡
"àÅ«à[Ît¡ "=¢¹à[Å (³õt塸¹ \>¸)
Accidental Rider Sum Assured (For Accidental Death and only if Accidental Rider has been opted)
ƒåQ¢i¡>à \[>t¡ ¹àÒül¡àì¹¹ "àÅ«à[Ît¡ "=¢¹à[Å (ƒåQ¢i¡>à \[>t¡ ³õt塸¹ \>¸ &¤} &A¡³ày ™[ƒ ƒåQ¢i¡>à \[>t¡ ¹àÒül¡à¹ [>¤¢àW¡> A¡¹à ÒìÚ =àìA¡)
Total Amount In Words (Rs)
Åì¦ ì³ài¡ "=¢¹à[Å (Rs)
Total Gratuity Amount Payable (Rs)
ì³ài¡ šøìƒÚ Nø¸àWå¡[Ú[i¡¹ š[¹³ào (Rs)
Note - Maximum Gratuity Exemption Allowed as per IT Act is Rs. 10, 00,000/
- with effective Date 24 May 10.
th
‰Ê¡¤¸ - "àÚA¡¹ "àÒü> ">å™àÚã Τ¢à[‹A¡ ">åì³à[ƒt¡ Nø¸àWå¡[Ú[i¡ "¤¸àÒ[t¡¹ š[¹³ào 10, 00,000/- i¡àA¡à ™à 24ëÅ ë³,10 ë=ìA¡ A¡à™¢A¡¹ Òì¤ú
Fund Option For Withdrawal
šøt¡¸àÒàì¹¹ \>¸ t¡Ò[¤º [¤A¡¿
Please select desired Contributions from which amount to be withdrawn (subject to availability of sufficient Fund)
">åNøÒ A¡ì¹ ëÎÒü A¡à[VÛ¡t¡ "¤ƒà>[i¡ [>¤¢àW¡> A¡¹ç¡> ë™[i¡¹ ë=ìA¡ "=¢¹à[Å šøt¡¸àÒ๠A¡¹ìt¡ W¡à> (™ì=Ê¡ [>[‹ l¡üšº®¡¸ =àA¡à¹ ÎàìšìÛ¡)
Initial Contribution
šøà¹[´±A¡ "¤ƒà>
Regular Contribution
[>Ú[³t¡ "¤ƒà>
Please select desired withdrawal %age of Amount from the given portfolio of funds in which Amount is to be withdrawn -
">åNøÒ A¡ì¹ šøƒv¡ ë™ t¡Ò[¤º ìšài¡¢ó¡[º* ët¡ "=¢¹à[Å šøt¡¸àÒ๠A¡¹à Òì¤ ëÎ[i¡¹ ë=ìA¡ "=¢¹à[Å šøt¡¸àÒàì¹¹ A¡à[VÛ¡t¡ Åt¡A¡¹à Ò๠[>¤¢àW¡> A¡¹ç¡>Pension Cash Fund
ëš>Å> A¡¸àÅ t¡Ò[¤º
Pension Income Fund
Pension Short Term Debt Fund
ëš>Å> Ѭ¿-ë³Úàƒã ˜¡o t¡Ò[¤º
Pension Debt Fund
ëš>Å> "àÚ t¡Ò[¤º
ëš>Å> ˜¡o t¡Ò[¤º
Pension Growth Fund
Others (If Any)
ëš>Å> [¤A¡àÅ t¡Ò[¤º
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Pension Balance
ëš>Å> ¤¸àìºX t¡Ò[¤º
Pension Secure Fund
ëš>Å> [>¹àšƒ t¡Ò[¤º
">¸à>¸ (™[ƒ =àìA¡)
A Joint Venture between Dabur and Aviva
Registered Office: 2nd Floor Prakashdeep Building, 7 Tolstoy Marg New Delhi 110001 India
l¡à¤¹ &¤} "[®¡®¡à¹ &A¡[i¡ ì™ï= l¡ü샸àK [>¤[Þê¡t¡ A¡à™¢àºÚ: 2Ú t¡º, šøA¡àŃ㚠[¤[Á¡}, 7 t¡ºÑzÚ ³àK¢
[>l¡ü [ƒ[À-110001 Òü[“¡Úà
Claims/GTICF/Ver1.1/01stDec11
Gratuity Cum Term Insurance Claim Form (GTICF)
Nø¸àWå¡[Ú[i¡ t¡=à ë³Úàƒã [¤³à ƒà[¤ ó¡³¢ ([\[i¡"àÒü[Î&ó¡)
Benefit Payment Method
Îå[¤‹à šøƒàì>¹ š‡ý¡[t¡
Please provide following details, if no option is exercised then refund would be processed through Cheque
">åNøÒ A¡ì¹ [>³¥[º[Jt¡ [¤¤¹o šøƒà> A¡¹ç¡>, ™[ƒ ìA¡à> [¤A¡¿ [>¤¢àW¡> >à A¡¹à ÒÚ t¡àÒìº "=¢¹à[Ź šøt¡¸š¢o šø[yû¡Úà ëW¡ìA¡¹ ³à‹¸ì³ δšÄ A¡¹à Òì¤
NEFT
CHEQUE
Account Number
&>Òü&ó¡[i¡
ëW¡A¡
"¸àA¡àl¡ü@i¡ >´¬¹
IFSC Code
"àÒü&ó¡&Î[Î ìA¡àl¡
Name of Trust (As mentioned in the Bank Record)
i¡öàìС¹ >à³ (¤¸à}A¡ ë¹A¡ìl¢¡ ë™®¡àì¤ l¡üìÀJ A¡¹à "àìá)
Bank Name
¤¸àìS¡¹ >à³
NEFT Stands for “National Electronic Fund Transfer”. In case you opt for NEFT payout facility, Please fill in the NEFT
mandate enclosed completely and get the same duly verified by your bank and submit it along with one cancelled
cheque / copy of pass book. If any information is missing in NEFT form, Payment will be made by Cheque.
&>Òü&ó¡[i¡-¹ "=¢ Òº ''>¸àÅ>ຠÒüìºCö¡[>A¡ ó¡à“¡ i¡öàXó¡à¹ú'' "àš[> ™[ƒ &>Òü&ó¡[i¡ ëš"àl¡üi¡ Îå[¤‹à [>¤¢àW¡> A¡ì¹> t¡àÒìº ">åNøÒ A¡ì¹ Î}™åv¡û¡ &>Òü&ó¡[i¡ ³¸àì“¡i¡[i¡
δšèo¢ ®¡àì¤ šè¹o A¡¹ç¡> &¤} ëÎ[i¡ "àš>๠¤¸à}A¡ ‡à¹à ™=à™= ®¡àì¤ šøt¡¸à[Út¡ A¡¹ç¡> &¤} &A¡[i¡ ¤à[t¡º A¡¹à ëW¡A¡ / šàΤÒüìÚ¹ A¡[š¹ ÎìU \³à [ƒ>ú ™[ƒ &>Òü&ó¡[i¡ ó¡ì³¢
ìA¡à> t¡=¸ "δšèo¢ =àìA¡ t¡àÒìº ëW¡ìA¡¹ ³à‹¸ì³ "=¢ šøƒà> A¡¹à Òì¤ú
Master Policy's Holder Declaration And Authority To Pay Claim ³àС๠š[º[Î ‹à¹ìA¡¹ ìQàÈoà &¤} ƒà[¤¹ "=¢ šøƒà> A¡¹à¹ ">å³[t¡
We hereby certify that the above member is eligible for Gratuity Benefit under the Policy No ___________________________________
and declare that the information shown above is true in each & every respect.
"à³¹à &t¡‡à¹à šøt¡¸à[Út¡ A¡¹[á ë™ l¡üšì¹àv¡û¡ ΃θ š[º[Î >}_________________________ &¹ "‹ãì> Nø¸àWå¡[Ú[i¡ Îå[¤‹à šà*Ú๠ì™àK¸
&¤} ìQàÈoà A¡¹[á ë™ l¡üšì¹ ƒ[Å¢t¡ ÎA¡º t¡=¸ Τ¢à}ìÅ Ît¡¸ú
Name of Trustee
Rubber Stamp
of Trust
Signature of
Member**
Signature of Trustee
i¡öàС-&¹ ¹à¤à¹
С¸à´š
΃ìθ¹
ѬàÛ¡¹ **
>¸àιۡìA¡¹ >à³
>¸àιۡìA¡¹ ѬàÛ¡¹
Address To Which Cheque And Confirmation Of Payment Should Be Sent ë™ [k¡A¡à>àÚ ëW¡A¡ &¤} "=¢ šøƒàì>¹ [>[ÆW¡t¡A¡¹o šàk¡àì>à Òì¤
Name of Contact Person
ì™àKàì™àK A¡¹à¹ ¤¸[v¡û¡¹ >à³
Designation
Postal Address
šƒ
[W¡[k¡ šàk¡àì>๠[k¡A¡à>à
City
ÅÒ¹
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A Joint Venture between Dabur and Aviva
Registered Office: 2nd Floor Prakashdeep Building, 7 Tolstoy Marg New Delhi 110001 India
l¡à¤¹ &¤} "[®¡®¡à¹ &A¡[i¡ ì™ï= l¡ü샸àK [>¤[Þê¡t¡ A¡à™¢àºÚ: 2Ú t¡º, šøA¡àŃ㚠[¤[Á¡}, 7 t¡ºÑzÚ ³àK¢
[>l¡ü [ƒ[À-110001 Òü[“¡Úà
Pin No
[š> >}
Claims/GTICF/Ver1.1/01stDec11
Gratuity Cum Term Insurance Claim Form (GTICF)
Nø¸àWå¡[Ú[i¡ t¡=à ë³Úàƒã [¤³à ƒà[¤ ó¡³¢ ([\[i¡"àÒü[Î&ó¡)
Standard Claims Checklist & Instruction
С¸à“¡àl¢¡ ƒà[¤ γèìÒ¹ ëW¡A¡[ºÐ¡ &¤} [>샢Åऺã
Please attach following documents to this Claim Form in case of Death Case
³õt塸¹ ëÛ¡ìy ">åNøÒ A¡ì¹ [>³¥[º[Jt¡ >[=P¡[º ƒà[¤ ó¡ì³¢¹ ÎìU Î}™åv¡û¡ A¡¹ç¡>-
1) Certified/Attested Copy of Death Certificate issued by Municipal Corporation
1) ìšï¹[>K³ ‡à¹à šøƒv¡ ³õt塸 Îà[i¡¢[ó¡ìA¡ìi¡¹ Å}[Ît¡ /šøt¡¸[Út¡ A¡[š
2) FIR, Post Mortem & News Paper Cutting (if any) [only if death happens due to an Accident and Accident Rider is opted)
2)
&ó¡"àÒü"à¹, ³Ú>à t¡ƒ”z &¤} Î}¤àƒšìy¹ A¡à[i¡} (™[ƒ =àìA¡) [&A¡³ày ™[ƒ ƒåQ¢i¡>๠A¡à¹ìo ³õt塸 Qìi¡ =àìA¡ &¤} ƒåQ¢i¡>à ¹àÒül¡à¹ [>¤¢àW¡> A¡¹à
ÒìÚ =àìA¡]
3) Pay slip for Last Month of Service / Full & Final Settlement Sheet
3)
W¡àA¡[¹¹ ëÅÈ ³àìι ëš [ÑÚ / δšèo¢ * Wè¡Øl¡à”z [>Íš[v¡ šy,
4) Attendance Record for the Month of Joining / Renewal of Member into the Scheme***
4) ë™ ³àìΠ΃θ šøA¡ì¿ ì™àKƒà>/šè>>¢¤ãA¡¹o A¡ì¹[áìº> ëÎÒü ³àìι l¡üš[Ñ‚[t¡¹ ë¹A¡l¢¡
Note-1) All fields are mandatory to be filled up
‰Ê¡¤¸- 1) ÎA¡º ëÛ¡y šè¹o A¡¹à ¤à‹¸t¡à³èºA¡,
2) The above mentioned documents are standard & indicative and additional info may be called for where necessary.
2) l¡üšì¹àv¡û¡ >[=šyP¡[º [>Ú³à>åK * [>샢ÅA¡ &¤} šøìÚà\> ">åÎàì¹ "[t¡[¹v¡û¡ t¡=¸ W¡à*Úà Òìt¡ šàì¹ú
* Gratuity Computation is preferable but important from required & accurate amount settlement point of view
*
Nø¸àWå¡[Ú[i¡ Ko>à A¡à³¸ [A¡”ñ šøìÚà\>ãÚ &¤} Î[k¡A¡ š[¹³àìo [>Íš[v¡¹ š[¹ìšø[Û¡ìt¡ P¡¹ç¡â«šèo¢
** Member Signature is Preferable,
** ΃ìθ¹ ѬàÛ¡¹ =àA¡à A¡à³¸
*** Applicable for all scheme where in Sum Assured Criteria is Anticipated and Actively at Work Clause is applicable
*** ìÎÒü ÎA¡º šøA¡ì¿¹ \>¸ šøì™à\¸ ë™Jàì> "àÅ«à[Ît¡ "=¢¹à[Å [>o¢àÚA¡ "ìš[Û¡t¡ &¤} Î[yû¡Ú ¹ê¡ìš A¡³¢¹t¡ ‹à¹à šø™åv¡û¡
A Joint Venture between Dabur Invest Corp. & Aviva International Holdings Limited
Aviva Life Insurance Company India Ltd
Head Office: Aviva Tower, Sector Road, Opp. DLF Golf Course, DLF Ph- V, Sector 43, Gurgaon-122003. Haryana India.
Registered Office: 2nd Floor, Prakashdeep Building, 7 Tolstoy Marg, New Delhi-110001. India
l¡à¤¹ Òü>쮡С A¡š¢ &¤} "[®¡®¡à Òü@i¡à¹>¸àÅ>ຠëÒà[Á¡}Î [º[³ìi¡ìl¡¹ &A¡[i¡ ì™ï= l¡ü샸àK
"[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l¡
ëÒl "[ó¡Î: "[®¡®¡à i¡à*Úà¹, ëÎC¡¹ ì¹àl¡, [l¡&º&ó¡ Kºó¡ ìA¡àì΢¹ [¤š¹ãìt¡, [l¡&º&ó¡ ëó¡\ V, ëÎC¡¹ 43, P¡¹Kòà*-122003ú Ò[¹Úà>à Òü[“¡Úàú
[>¤[Þê¡t¡ A¡à™¢àºÚ: 2Ú t¡º, šøA¡àŃ㚠[¤[Á¡}, 7 t¡ºÑzÚ ³àK¢, [>l¡ü [ƒ[À-110001ú Òü[“¡Úà
Tel/ ëi¡[ºìó¡à>:+91 (0) 124 270 9000 Fax/ ó¡¸àG: +91 (0) 124 257 1210.
www.avivaindia.com Email/ Òü쳺 :[email protected]