PRS No.

90000/

Attach a passport-
size photo taken in
the last 6 months. PERSONAL RETIREMENT SCHEME
APPLICATION FORM
(Provident Fund)
ICEA LION Centre, Riverside Park, Chiromo Road, Westlands • P.O. Box 46143 - 00100, Nairobi, Kenya • Tel: 020 2750 000
• Tel: 0719 071000 • Fax: +254 (20) 2244 258 • Email: life@icealion.com • Website: www.icealion.com

Please complete this form in BLOCK CAPITALS and tick boxes where applicable.

SECTION 1: PERSONAL DETAILS

Title: Mr. Mrs. Ms. Dr. Prof. Other. Please Specify

Full Name SURNAME FIRST NAME MIDDLE NAME

Date of birth DD - MM - YYYY Gender Marital Status

ID/Passport Number KRA PIN Number

(attach copy) (attach copy)

Country of Residence Occupation

Employer’s Name

Private Email Address

Mobile Number Office Number

P.O. Box Code Town

RESIDENTIAL AND UTILITY DECLARATION

Kindly fill the section below OR attach your latest utility bills (Electricity, Water or Telephone):

Residence Area Land Reg. No. (L.R.No.)

Estate Name House No.

Town/Area

BANKING DETAILS

Bank Name Branch Name

Account Name Account No.

SECTION 2: RETIREMENT AGE & CONTRIBUTIONS

Selected Retirement Age: (Max: 75 years; Min.: 50 years)

Source of Funds

Employee Employer
NSSF Tier 2 Contribution
Regular Contribution as a percentage
of salary or in KShs.
Post-Retirement Medical Fund
Contribution
Lump-sum Contribution* [KShs.]
[*Attach a benefit computation worksheet for benefits being transferred into your account from another retirement benefits scheme or Provide details and attach
evidence of other sources of funds.]

Date of Commencement

MODE OF REMITTANCE
Paybill No: 974203
Bankers Order Salary Deduction Personal Cheques M-Pesa Account No: National ID or Policy number.

Payment Frequency: Per Month Per Quarter Per Half Year Per Year

SECTION 3: BENEFITS ELECTION

PROVIDENT FUND
 SECTION 4: PROTECTION BENEFITS

Do you have other policies with us? Yes No

If yes, please specify the type of Policy

Do you wish to include Death-in-Service benefits? Yes No

SECTION 5: INTERMEDIARY DETAILS

Branch Unit

Intermediary Name Signature/Stamp Date

Unit Leader's Name Signature Date

Signature of the Applicant

SECTION 6: NOMINATION OF BENEFICIARIES

To The Corporate Trustee,

I wish you to consider these persons as possible recipients of death benefits in the proportions shown. I understand that in exercising discretion in
applying the benefit, The Corporate Trustee of the fund will not necessarily be bound by this expression of my wishes.
PARTICULARS OF NOMINEES
Relationship National ID/ Share
Full Name of Beneficiary to Member Date of Birth Passport No. Telephone No. Postal Address (%)

Guardian for beneficiaries under the age of 18 years

Relationship to
Name of Guardian Telephone No. beneficiary Beneficiary

Note: (i) Continue the nomination of beneficiaries on a separate form if necessary.

(ii) Note: If your personal circumstances change at any time after returning this form, you should submit a new form without delay.
(iii) ICEA LION Life Assurance Company Limited administers the Scheme.
SECTION 7: DECLARATION BY THE APPLICANT

A. I, ____________________________________________________________________________, hereby apply for a Personal Retirement

Scheme on the standard terms and conditions of ICEA LION Life Assurance Company Limited and confirm that to the best of my knowledge
and belief the statements contained herein are true and complete. I confirm that this application shall form the basis of the contract between me
and The ICEA LION Life Assurance Company Limited.
B. I have read and understood the privacy notice on the ICEA LION Group website (https://icealion.co.ke/icea-lion-group-data-privacy-notice)
relating to use of my personal data. Specifically, by accepting this declaration, I acknowledge that ICEA LION Life Assurance Company
Limited (“our” or “us)’ will use my personal data to administer my retirement benefits. This may include availing my personal data where
necessary to a Fund Actuary, Fund Administrator, Scheme Auditor & Regulators as part of the benefits administration process. Further, if
applicable, I consent to the processing of personal data of the child/children provided as beneficiaries in this form. I acknowledge that my
personal data may also be used to bring to my attention information about ICEA LION Group’s products and services that may be of interest
to me. By selecting the channel(s) below, I consent to receiving marketing information about ICEA LION Group’s products and services.
SMS Email Telephone WhatsApp

Signed: __________________________________________________ Signed: ___________________________________________________

(Applicant) (Policyholder (if different from applicant))

Date: ___________________________________________________ Date: ___________________________________________________

 SPECIAL CONDITIONS AND PROVISIONS

1. This Deed of Adherence is supplemental to the Trust Deed (hereinafter referred to as “the Trust Deed”) dated the Sixteenth Day of June
Year Two Thousand and Nine made between the Founder (ICEA LION Life Assurance Company Limited) and the Trustee establishing the
ICEA LION Individual Retirement Benefits Scheme (hereinafter referred to as the “the Scheme”) for providing benefits for Individuals in
accordance with the Rules of the Scheme.
2. The Individual and the Trustee hereby covenant with each other to perform and observe the agreements and stipulations contained in the
Trust Deed & Rules so far as the same are or ought to be performed and observed by them respectively, so that no personal liability shall be
attached to any of them except in respect of their individual acts, neglects or defaults in relation to the trusteeship.
3. All Retirement Benefits derived from contributions from an Individual and a Contributing Employer shall immediately vest in the member.
Notwithstanding anything to the contrary, the benefit derived from the NSSF Tier 2 contributions in respect of a Member shall immediately
and fully vest in the Member upon payment to the Member’s account in the Scheme.
4. The Scheme shall pay all reasonable charges and expenses incurred by the Trustee in connection with the administration of the Fund. Such
expenses shall be disclosed in the annual financial statements of the Scheme;
5. This Deed of Adherence shall be terminated once the Individual cease to participate in the Scheme as provided in the Trust Deed & rules.
The Individual is required to give a notice of termination of the Scheme in writing to the Trustee. The individual shall be paid benefits in
accordance with the Trust Deed.
6. In respect of the Post-Retirement Medical Fund:
A. The individual may upon attaining early or normal or late retirement age transfer up to ten percent (10%) of the accumulated
retirement fund and all the accrued benefits from the additional voluntary contributions to a Medical Cover Provider such as a Post-
Retirement Medical Fund or National Hospital Insurance Fund or an Insurer, Broker or Medical Insurance Provider registered under
the Insurance Act.
B. Upon attaining early or normal or late retirement age, an individual and his/her spouse where applicable, may access their medical
benefits in any of the following ways:
(i) Retaining the funds within a Post-Retirement Medical Fund and utilize it to purchase a medical cover by paying annual
premiums.
(ii) Retaining the funds within a Post-Retirement Medical Fund and paying medical expenses incurred as and when they fall due.
(iii) Transferring the accrued amount to a medical cover provider other than another post-retirement medical fund for the
purpose of purchasing a medical cover or offsetting any medical expenses incurred as and when they fall due
(iv) Purchasing an annuity for the purpose of paying annual medical cover premiums.
7. Upon Early or Normal or Late Retirement Date, the Individual shall be entitled to all accumulated contributions plus interest outstanding in
his account as at the date of retirement and the same shall be paid out as follows:
7.1. The Fund Credit arising from regular contributions and the investment income thereon shall be paid in a cash lump sum.
7.2. The NSSF Tier 2 Fund Credit shall be accessed in the form of:
A. A non-commutable and non-assignable pension benefit guaranteed for a minimum of ten (10) years to provide the individual
with an income for life in the form of an annuity in accordance with the immediate annuity rates available from the Insurance
Company PROVIDED THAT;
(i) The Member will have the opportunity of selecting his preferred Annuity service provider.
(ii) An individual will have the option of receiving a maximum of 1/3 of his accumulated contributions plus interest
earned in the form of cash lump sum.
(iii) If the balance of an individual’s accumulated amount will result into “trivial pension” themember will be allowed to
take the entire amount in one lump sum. The “trivial pension” amounts will be determined by the Authority from
time to time.
B. An income drawdown purchased from a duly registered Income Draw down Fund of a member’s choice for a minimum
drawdown period of ten (10) years to provide the member with a Regular Income.
IN WITNESS WHEREOF this Deed of Adherence has been signed by:

Contributor:
Name: ____________________________________________________________________________________

Signed: __________________________________________________ Date: ___________________________

And on Behalf of Corporate Trustee:

Processed/Created by
Name: ____________________________________________________________________________________

Signed: __________________________________________________ Date: ___________________________

Approved By:

Name: ____________________________________________________________________________________

Signed: __________________________________________________ Date: ___________________________