[Regulation 83A]

CLAIM FOR PERIODICAL PAYMENTS

Name of the deceased insured person ____________________

Insurance No ___________________________

    I ,______________________________ (state relationship with the deceased) ________ of the above named insured person, being his dependant, claim dependants’ benefit for the period from _______ to _______

    The amount due may be paid to me (by money order) / (in cash at the local office)

     I declare that I have not married/ remarried so far (*)

    I certify that I have not attained the age of eighteen years and am continuing my studies in _______________ fifteen years**

    I declare that I am still infirm***

Signature or thumb impression of the claimant

Present address ____________

Dated ______  

*Applicable only in case of female dependants.

** Applicable only in case of minor dependants.

*** Applicable only in case of legitimate infirm son or legitimate or adopted unmarried infirm daughter. The claim in such cases shall be accompanied, if required, by a certificate of specified authority.

Note: In case of a minor, the guardian should sign the claim on behalf of the minor, and the following words below his signature ________________________

(Name of the minor) through _____________________

(Name of the guardian) his/her ____________________________________ relationship.