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:
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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 |
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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:
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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 |
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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.
