UPT PERSONAL PENSION FORM

UPT PERSONAL PENSION FORM

VANGUARD HOUSE #21 INDEPENDENCE AVENUE RIDGE, PMB 108, AIRPORT, ACCRA, GHANA Tel: (233) 20 182 3991 / 20 182 3943
AGENT CODE
SECTION 1: PERSONAL DETAILS
NAME*

PrefixFirst NameLast Name
GENDER*

MaleFemale
DATE OF BIRTH*

DayMonthYear
Date
PLACE OF BIRTH:*
EMAIL*
example@example.com
PHONE NUMBER:*
SOCIAL SECURITY NUMBER:
PHYSICAL / DIGITAL ADDRESS:
POSTAL ADDRESS:
NATIONALITY*
OCCUPATION
NATIONAL ID (prefarably Ghana Card)
Initial/Starting Amount
MARITAL STATUS*

SingleMarriedWidowedSeparatedDivorced
SECTION 3: BENEFICIARY

BENEFICIARIES (IN EVENT OF MY DEATH, ANY BENEFITS ACCRUING TO ME UNDER THE FUNDSHALL BE PAID TO MY BENEFICIARIES INDICATED BELOW). IF BENEFICIARY IS BELOW 18YEARS , KINDLY FILL THE TRUSTEE COLUMN.

	NAME OF BENEFICIARY	RELATIONSHIP	% OF BENEFIT DUE TO THE BENEFICIARY	DATE OF BIRTH	CONTACT
1
2
3
4
5
6
7
8
9
10

SUM OF BENEFICIARY:
The sum of your beneficiaries is {sumOf}. It should add up to 100%.

	TRUSTEE'S NAME	RELATIONSHIP	DATE OF BIRTH	CONTACT/ADDRESS
1
2

DECLARATION BY PARTICIPATING EMPLOYEE

I certify that the contents of the membership enrolment form are accurate.
Signature

Clear
Or Take Photo of Signature
Date*

MonthDayYear
Date
MODE OF PAYMENT
Mode of payment*

MANDATE-PAY POINT DEDUCTIONDIRECT DEBITSTANDING ORDERONLINE PAYMENT
MANDATE-PAY POINT DEDUCTION
Name

First NameLast Name
Name Of Employer
Staff / Payroll / Employee or Service No:

Basic Salary
Rate %
Monthly Contribution (GHS)*
I, do hereby authorize the accountant or accounts officer or the pay office to deduct from my salary the stated monthly contribution and future increases and remit same to united investment trust, monthly with effect from date . Until otherwise notified in writing.
Signature

Clear
Date

MonthDayYear
Date
Or Take Photo of Signature
DIRECT DEBIT
Name

First NameLast Name
Address
National ID No.
Mobile Number

Area CodePhone Number
Email
example@example.com
PAYMENT DETAILS
Premiums (GHS)*
Amount In Words*
Date Of First Deduction*

MonthDayYear
Date
Subsequent Deductions

DAILYWEEKLYMONTHLYQUARTERLYYEARLY
INSTRUCTION TO BANK
Name Of Bank
Branch Where Account Is Held
Sort Code
Type Of Account

CURRENTSAVINGOTHERS
Bank Account Name
Bank Account No.
I/We the undersigned hereby authorize the Bank to deduct My/Our monthly premium for My/Our investment as indicated above subject to the terms and conditions provided below. United Pension Trustees Limited is hereby indemnified against any claim or liability that may arise but not limited to My/Our providing the wrong bank details, policy number, or any other error in My/Our instructions in respect of which United Pension Trustees Limited acts in implementing My/Our direct authorization. I/We understand that the withdrawals hereby authorized will be processed through an automated clearing house platform provided by Ghanaian Banks.
TERMS AND CONDITIONS
• The efficiency of The Direct Debit Scheme is monitored and protected by all parties involve.
• If any error is made by any of the parties involve, you are guaranteed a full and immediate refund to own bank account by the originator of the error.
• The client can cancel this mandate at any time by writing to United Pension Trustees Limited within Thirty (30) working days in advance of your account being debited.
• United Pension Trustees Limited has agreed to advance notice of the amount at least Ten (10) days before the date of first debit.
The notice will be provided by electronic means by e-mail and SMS where the contributor has provided them.
Signature

Clear
Date

MonthDayYear
Date
Or Take Photo of Signature
STANDING ORDER
Account Name: UNITED INVESTMENT TRUST

Account Number: 0176909140003

Bank: CONSOLIDATED BANK GHANA (CBG)

Branch: KOKOMLEMLE

Sort Code: 340108

NB: Kindly attach your Fullname and Policy Number
ONLINE PROCEDURE
- Log onto our website: www.upt.com.gh
- Click on ONLINE PAYMENT
- Enter your Policy Number , Full Name and AmountOnly enter the Amount you want to pay in the “Amount Box” (NB: The usual Mobile Money charges applies.
- click on CHECKOUT. This takes you to the Payment window, showing your details and the Payment options i.e. Mobile Money, Visa/MasterCard, GTBank Account
Should be Empty:

	ADDRESS	REGION	TOWN
1
2
3

UPT PERSONAL PENSION FORM

SECTION 1: PERSONAL DETAILS

SECTION 3: BENEFICIARY

DECLARATION BY PARTICIPATING EMPLOYEE

MODE OF PAYMENT

I, do hereby authorize the accountant or accounts officer or the pay office to deduct from my salary the stated monthly contribution and future increases and remit same to united investment trust, monthly with effect from date . Until otherwise notified in writing.