Application form for transfer of accrued pension rights
(value transfer)
Use this form to transfer to Delta Lloyd the value built up in one or more
previous pension schemes.
Instructions
Fill in this form on a computer. When you are finished, click the send button
at the bottom of the form. Or send it by e-mail to
[email protected].
You can also print and send the form to the following address
(no stamp required):
Value transfer
Delta Lloyd Levensverzekeringen N.V.
Antwoordnummer 2052
1000 PA Amsterdam
Date
Personal details of member
Name and initials Gender
Male
Female Date of birth
Citizen Service Number
Address
Postcode and town/city
New employer
Name Address
Postcode and town/city
Employment start date
Scheme number
(Employees can find their scheme number on their pension statement. Leave the
number blank if you have not yet received a pension statement from us.)
1 Previous employer *
Name Business location
* There is space on the next page to enter additional employers and pension administrators.
1 Previous pension administrator
Name Business location
XY 15097-0215
Policy or registration no.
Antwoordnummer 2052
1/2
1000 PA Amsterdam
[email protected]
2 Previous employer
Name Business location
2 Previous pension administrator
Name Business location
Policy or registration no.
3 Previous employer
Name Business location
3 Previous pension administrator
Name Business location
Policy or registration no.
Antwoordnummer 2052
1000 PA Amsterdam
delete
2/2
[email protected]
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