Member Benefits Claim Form

Member Benefits Claim Form

TPD|Terminal Illness|Death|Spousal|Dismemberment and Major Burns| Withdrawal
Use this form for: TPD, Terminal Illness, Death, Spousal, Dismemberment and Major Burns, and Withdrawal claims. For Retirement or Early Retirement claims, use Retirement Claim Form
1. Claim Details
Claim type
Withdrawal type
Voluntary Withdrawal amount (NZ$)
Contract type
2. Member Details
RMD Number
CINSF Member Number
Title

Other
First name(s)
Surname
Residential address (Member)
Date of birth (Member)

DayMonthYear
Date
Sex at birth
Home phone

Area CodePhone Number
Mobile phone

Area CodePhone Number
Email address (Member)
example@example.com
Final payroll contribution date

DayMonthYear
Date
Current employer name
3. Death or Spousal Claims - (Applicant Details)
Applicant full legal name

First NameMiddle NameLast Name
Relationship to deceased member
Applicant date of birth

DayMonthYear
Date
Applicant Residential address
Applicant Telephone/Mobile

Area CodePhone Number
Applicant Email address
example@example.com
4. Payment / Bank Details
Bank name
Bank number
Branch
Branch number
Account number
Account name
SWIFT code (Overseas accounts only)
Bank address (overseas accounts only)
5. Declarations and Signature
By Signing below, you confirm that each of the following statements is true:

I. I have completed this form carefully, and to the best of my knowledge, all information provided is true and correct.

II. I acknowledge that CINSF may verify any information provided and may request additional documentation during processing.

III. I authorise CINSF to process this claim and make payment in accordance with the details provided above.

IV. I understand that providing false or misleading information may result in delays, recovery of payments, or other action under the Fund Rules or applicable law.
Signature
File Upload or email to enquiry@superfund.gov.ck

Cancelof
Should be Empty:

Member Benefits Claim Form

1. Claim Details

2. Member Details

3. Death or Spousal Claims - (Applicant Details)

4. Payment / Bank Details

5. Declarations and Signature