CLAIM FORM
TICK THE TYPE OF BENEFIT
Retirement
Early Retirement
Compulsory balance LESS than $60,000
FULL WITHDRAWAL
PARTIAL WITHDRAWAL
Compulsory balance GREATER than $60,000
PARTIAL WITHDRAWAL
If you selected partial withdrawal, what percentage (max 25%) are you requesting to withdraw? The remaining balance will transfer to pension payment
Which claim are you wanting to make?
Total and Permanent Disability
Terminal Illness
Death
Prepayment Funeral
Spousal Pension
Withdrawal by Contract Worker - less than 3 years
Withdrawal by Contract Worker - more than 3 years
Dismemberment and Major Burns
Voluntary Withdrawal $
(Note: One withdraw allowed per year)
MEMBER INFORMATION
RMD Number
CINSF Member Number
Title
Mr
Mrs
Ms
Dr
Other
First name(s)
Surname
Residential Address
Home Phone
-
Country Code
Phone Number
Mobile Phone
-
Country Code
Phone Number
Email Address
example@example.com
Gender
Male
Female
Date of Birth (DD/MM/YYYY)
-
Month
-
Day
Year
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Age
Final Payroll Contribution Date
-
Month
-
Day
Year
Date Picker Icon
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APPLICANT DETAILS
Applicant Name
Address
Telephone
Format: (000) 000-0000.
Email Address
example@example.com
Relationship to Member
PAYMENT DETAILS
Bank
Bank Number
Branch
Branch Number
SWIFT Code
Account Number
Account Name
MEMBER /APPLICANT DECLARATION AND SIGNATURE
By signing this declarations:
I. I confirm that I have throughly reviewed and comprehends the pension and claim options provided by the Cook Islands National Superannuation Fund.
II. I declare that I have completed this form after careful cosideration of all available options, ensuring a comprehensive understanding of the choices offered to me.
III. I acknowledge that my pension funds will remain subject to investment and are susceptible to fluctuations in value until the claim is approved and payment is finalized.
IV. I understand that the value of my funds may rise or fall during period.
Signature
Date
-
Month
-
Day
Year
Date
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