Form 18 – EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS,1950

FORM 18: Dependants’ Benefit

[Regulation 80]

CLAIM FORM

    Claim arising from the death on ____________ of (insured person)____________________ son/wife/ daughter of ___________ having Insurance No ________ and last employed as _______ by ___________

    I/We the following, being dependants of the deceased insured person, whose particulars are given above, apply for dependants’ benefit in respect of his/her death:

Name and address of   the dependant

Date of birth or age

Relationship with the deceased

Sex

Marital status

 Name of the guardian in case of a minor

 

 

 

 

 

 

So far as I/we know the following are the only other dependants who may be entitled to dependants’ benefit in respect of the death of the above- named insured person:

Name and address of the dependant

Date of birth or age

Relationship with the deceased

Sex

Marital status

Name of the guardian in case of a minor

 

 

 

 

 

 

I/We declare that the particulars given above are true to the best of my/our knowledge and belief.

Signatures                                                                                Present address

1______________                                                               __________________

2______________                                       __________________

3______________                                       __________________

4______________                                                    

    *Certified that the declarations made above are true to the best of my knowledge and belief.

Signature _________

Designation ________

Rubber stamp or seal of the attesting authority

* This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Departments of Government; or (ii) a Municipal Commissioner; or (iii) a Workmen’s Compensation Commissioner; or (iv) the Head of the Gram Panchayat under the official seal of the Panchayat; or (v) any other authority approved by the appropriate Regional Office.

Note: Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself or for some other person renders himself liable to prosecution.

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