Form 14 "Application for Financing a Life Insurance Policy out of the Provident Fund Account" - India
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4Employees Provident Fund Scheme
Form 14
(Paragraph 62 of the Employees’ Provident Funds Scheme, 1952)
Application for Financing a Life Insurance Policy
out of the Provident Fund Account
To,
The Commissioner,
Employees’ Provident Fund,
……………………………………………..
I …………………………………………….. s/d/w/of……………………………
(Name in block capitals)
an employee of ………………………………………………………………. authorise
(Name of the establishment)
the Commissioner to –
(i)
withdraw a sum of Rs. ………. (Rupees……….0 from my Provident
Fund Account No. ……… and remit the same to the Life Insurance
Corporation of India towards the initial premium in respect of my
Life Insurance Policy/Proposal for Life Insurance details of which
are given herein –
(ii)
make periodical withdrawal of Rs……(Rupees…..) from my
Provident Fund Account No……. each time the premium falls due
for payment and remit the same to the Life Insurance Corp0ration
of India towards the premia in respect of my Life Insurance
Corporation of India and I inform the Regional Commissioner
accordingly;
(iii)
to convert the said insurance policy into a paid-up one when the
credit in my provident fund relating to my own contribution becomes
inadequate for the payment of any premium, unless the payment of
further premium is arranged by me with the Life Insurance
Corporation of India and I inform the Regional Commissioner
accordingly;
(iv)
to pay late fees and/or interest of my own contribution in my
provident fund account If any premium cannot be remitted to the
said Corporation in time because of delay in sending to the
Commissioner the policy duly assigned to the Central board of
Trustees of the Employees’ Provident Fund or any other reason for
which I or my employer may be responsible.
2.
I accept that -
Employees Provident Fund Scheme
Form 14
(Paragraph 62 of the Employees’ Provident Funds Scheme, 1952)
Application for Financing a Life Insurance Policy
out of the Provident Fund Account
To,
The Commissioner,
Employees’ Provident Fund,
……………………………………………..
I …………………………………………….. s/d/w/of……………………………
(Name in block capitals)
an employee of ………………………………………………………………. authorise
(Name of the establishment)
the Commissioner to –
(i)
withdraw a sum of Rs. ………. (Rupees……….0 from my Provident
Fund Account No. ……… and remit the same to the Life Insurance
Corporation of India towards the initial premium in respect of my
Life Insurance Policy/Proposal for Life Insurance details of which
are given herein –
(ii)
make periodical withdrawal of Rs……(Rupees…..) from my
Provident Fund Account No……. each time the premium falls due
for payment and remit the same to the Life Insurance Corp0ration
of India towards the premia in respect of my Life Insurance
Corporation of India and I inform the Regional Commissioner
accordingly;
(iii)
to convert the said insurance policy into a paid-up one when the
credit in my provident fund relating to my own contribution becomes
inadequate for the payment of any premium, unless the payment of
further premium is arranged by me with the Life Insurance
Corporation of India and I inform the Regional Commissioner
accordingly;
(iv)
to pay late fees and/or interest of my own contribution in my
provident fund account If any premium cannot be remitted to the
said Corporation in time because of delay in sending to the
Commissioner the policy duly assigned to the Central board of
Trustees of the Employees’ Provident Fund or any other reason for
which I or my employer may be responsible.
2.
I accept that -
(i)
The authorisation at Para I(ii) above shall be effective only when
my life, insurance policy duly assigned to the Central Board of
Trustees, Employees’ Provident Fund has been received by the
Commissioner after proper registration of the assignment in the
books of the said Corporation.
(ii)
The said authorisation shall thereafter remain operative till such
time as I continue to be a member of the fund and have enough
accumulations to my credit as my own share in the fund, or till the
maturity of the policy, whichever is earlier.
(iii)
The terms of the policy shall not be altered nor shall the policy be
exchanged for another policy without the prior written consent of
the Regional Commissioner.
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The policy is enclosed for inspection/will be forwarded when received/has
already been assigned to the Central Board of Trustees of the Employees’
Provident Fund and accepted by the Commissioner vide his letter
No……….. dated the ………………
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I am aware that the policy is to be assigned to the Central Board of
Trustees of the Employees’ Provident Fund as Security within six month is
of the date of the first remittance by the fund to the said Corporation and
sent to the Commissioner after registration of the assignment in the books
of the said Corporation.
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I declare that –
(a)
I have been a member of the fund for the period of not less than
two years which is the minimum period for being eligible for
financing the insurance policy from the fund.
(b)
The amount standing to my credit in my E.P.F Account (my own
share) is Rs……………….. as on ………………….. which is
sufficient for making payment to LIC for two years.
(c)
My annual contribution to the fund is Rs. …………… which is
sufficient to pay my yearly premia.
(d)
I propose to nominate the same person as for the P.F.
6.
I also declare that the policy is free from any encumbrances and the
details of the *policy/proposal given herein are correct to the best of my
knowledge.
1.
Details of the *policy/proposal :
(i)
Address of the Branch office or unit of the Life
Insurance Corporation where the policy account * is to be
maintained.
(ii)
*Policy/proposal No. & date.
(iii)
Sum assured/proposal to be assured.
(iv)
Probable date of purchase of the policy
(v)
Whether the proposal has been accepted and if so,
By what date the first premium is to be paid.
(vi)
Cost of the policy (in the case of single payment policies)
(vii)
Amount of yearly permia.
(viii)
Due date(s) for payment of premium.
(ix)
Date of pyament of last premium.
(x)
Whether age has been admitted. If not state the nature of proof
presented to Life Insurance Corporation.
(xi)
Name(s) of the nominee(s) under Section 39 of the Insurance Act,
1938.
(xii)
Guardian appointed under Section 39 of the Insurance Act, 1938 in
respect of minor nominees, if any.
(xiii)
Details of any previous policy already assigned to the C.B.T,
Or
“Certified that I have not withdrawn any amount previously for
financing out of my provident fund account.”
(xiv)
Remarks.
Date………………….
**Signature or left/right thumb
impression of the member
Certified that this form has been *signed/thumb impressed before me by…………
(Name of member)
Account No………………….. employed………………………………..
(Name of establishment)
Signature of the employer of his
authorised official
Date ……………………
Designation……………………….
Code No. of the Estt……………..
Name and address of the
Establishment and its stamp
* Delete portion if not applicable.
** Left hand thumb impression in the case of illiterate male member and right
hand thumb impression by illiterate female member.
For use in Regional Commissioner’s Office
(Accounts Section)
Please furnish the following information in respect of the subscriber :
Average of yearly
Total contributions
Whether any other
Whether the
contribution
(Employees’ share
L.I.P. Advance
subscriber has
(Employees’ share
only) as on
has been granted
contributed for two
only) on the basis
before, f so,
years.
of recent 12
mention the date
months Form No.
of the withdrawal
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The above case has been examined vide Paras 62 to 64 of the Employees’
Provident Funds Scheme, 1952. A sum of Rs. ……………(Rupees……….) may
be paid.
Clerk
Head Clerk
Accounts Officer
R.P.F.C.
Insurance Section
D.P. Sheet prepared and put up for signature
Clerk (ins.)
Head Clerk (ins.)
Accounts Officer
R.P.F.C.
