Form 14 - Application For Financing A Life Insurance Policy Out Of The Provident Fund Account

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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 -

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