Steps for filling Provident Withdrawal form

• You are requested to clearly mention all the details from point no.1 to point no.11.

• Signature at the bottom of the page 1

• PF will be credited only to ICICI Bank account .Kindly provide the cancel cheque incase of non salary ICICI Bank account .

• Signature on Page 2 below Declaration of Non Employment

• Signature of the employee on Page 2 .Fix the Re.1 revenue stamp and need to sign across.

• You need to attach the copy of Permanent Account Number (PAN) along with the form. It is mandatory as per the Income Tax, or else your form will be rejected .

Steps for filling Pension Withdrawal form

• Mention your Employee Code on top of the Pension Withdrawal Form

• You are requested to clearly mention all the details in BLOCK LETTERS from point no.1 to point no.3

• Point no 4,5,6 leave it blank

• Point No.9, 10, & 12 – Please leave it blank

Point no.11 please mention the complete Bank branch address

• It is Mandatory to attach “ORIGINAL CANCELLED CHEQUE “along with the Pension with-drawal form pertaining to any of the saving Bank account number mentioned on point no 11 or else the form will get rejected by the Regional Provident Fund Commissioner .

• Signature on bottom of the Page 2 where (X) is marked . Fix revenue stamp & signed across on Page 3 & keep all the details blank

• Page 4 please keep it blank

• Address for sending the PF and Pension withdrawal form

ICICI Prudential Life Insurance Company LimitedShared Services –PF DepartmentGround Floor, Vinod Silk Mills Compound,Ashok Nagar, Chakravarti Ashok Road, Kandivali (E), Mumbai -400101

ICICI PRUDENTIAL LIFE INSURANCE CO. LTD. EMPLOYEE’S PROVIDENT FUNDPROVIDENT FUND WITHDRAWAL FORM

ICICI Prulife Towers, 1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai – 400025

1. Name of the member _______________________________________________________ (In block letter)

2. Employee Code ______________________________________________________

3. Father’s Name (or husband’s name ______________________________________________________ in the case of married women)

4. PF Account No. _____________________________________________________ (Same as Employee Code)

5 Employee PAN No. _______________________________________________________ (Mandatory)

6. Date of leaving service _______________________________________________________

7. Reason for Leaving Service RESIGNED

8. Full postal address (In block Letters) _______________________________________________________

_______________________________________________________

_______________________________________________________

PinCode:______________________State_____________________

9. Email ID (Personal) _______________________________________________________

10. Mobile No. _______________________________________________________

11. Mode of Remittance ( √) put a “TICK” in the box against the one opted

a) By account payee cheque to be sent

At the address given against serial no. 8 ( ) (Name to be appeared on Cheque) _________________________________________________

(IN BLOCK LETTERS) b) By credit to my S.B. Account No. _____________________________

Name of the Bank: - ICICI Bank Ltd(Advance stamped Receiptfurnished below) Branch ____________________________________________

Full address of the branch _____________________________ __________________________________________________

X Signature of the member

Address for sending the form- ICICI Prudential Life Insurance Co. Ltd.- Shared Services-PF DepartmentGr. Floor, Vinod Silk Compound, Chakravarthy Ashok Road, Ashok Nagar ,Kandivali - East, Mumbai - 400 101

Certified that the particulars are true to the best of my knowledge

Date of joining the establishment : _________________________________

Date of Leaving Service : _________________________________

The applicant has signed / thumb impressed before me.

X Signature of the member

ICICI PRUDENTIAL LIFE INSURANCE CO. LTD

EMPLOYEE’S PROVIDENT FUND

Trustees.

Encl.

DECLARATION OF NON-EMPLOYMENT

I declare that I have not been employed in any factory / establishment to which the EPF & MP Act, 1952 applies for a continuous period not less than 2 months immediately proceeding the date of my application for final withdrawal of my Provident Fund money.

X Signature of the memberDate:

ADVANCE STAMPED RECEIPT

Received a sum of Rs. __________________( Rupees _______________________________________________

From ICICI PRUDENTIAL LIFE INSURANCE CO. LTD. EMPLOYEE’S PROVIDENT FUND towards the settlement of my Provident Fund account.

Cheque No. _____________________ Date:_______________________

X Signature of the member (For office use only)

Account settled in Part / Full Entered in Withdrawal Register

ICICI PRUDENTIAL LIFE INSURANCE CO. LTDEMPLOYEE’S PROVIDENT FUND

Trustees

Address for sending the form- ICICI Prudential Life Insurance Co. Ltd. -Shared Services-PF DepartmentGr .Floor, Vinod Silk Compound, Chakravarthy Ashok Road, Ashok Nagar, Kandivali - East, Mumbai - 400 101

Rs. 1.00RevenueStamp