(Please complete the form in BLOCK LETTERS and tick where applicable)


I hereby apply for membership of the Octagon Personal Pension Scheme as required by the scheme eligibility conditions.

SECTION 1 Personal Details _______________________________________________________________________________

Sex:MaleFemale     Marital Status:MarriedSingle

SECTION 2 Contributions _______________________________________________________________________________

Method of Payment: Salary Deduction Standing Order Cheque Direct Debit Mpesa
Mode of Payment: Monthly Quarterly Half-Yearly Yearly
Contribution Amount:        
 Transfer from Retirement Scheme  
Preferred Retirement Age
50 years,   55 years,   60 years,   65 years,   70 years,   75 years,  

I confirm that to the best of my knowledge and belief the information I have provided herein is true and complete
NOTE: Any employer portion transferred into this scheme will only be accessed at the selected retirement
age except on death or emigration.

SECTION 3 Beneficiary Nomination Form ____________________________________________________________________

I hereby request you to pay benefits due upon my death while still a Member of the Octagon Personal Pension Scheme
under the Rules thereof to the undermentioned Nominated Beneficiaries in the proportions shown against each name:

  1st Beneficiary 2nd Beneficiary 3rd Beneficiary 4th Beneficiary
Telephone No.
Relationship to me:
Date of Birth (yyyy-mm-dd)
National ID No.

I understand that the Trustees of the scheme have the final discretion to decide who should receive benefits under the scheme.
This nomination cancels and supersedes any previous nomination.

SECTION 4 Attachments _______________________________________________________________________________

Kindly attach copies of your national ID, KRA pin, birth certificates of your nominated beneficiaries who are minor or national
IDs of those who are eighteen years and above in JPEG, PNG or PDF formats.
Select Files: