Dependants’ Benefit - Claim Form for Periodical Payments

Form 18A
(See Regulation 83A)

Name of the deceased insured person

Insurance No. ……………….

I, ………………………. (State relationship with the deceased) ……………………. of the above named insured person, being his dependant claim Dependant’s 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 ()

Strike out what is not applicable

 I declare that I am still infirm

Signature or thumb-impression 
of the claimant

Date …………					
Present address ………………….

() Applicable only in case of female 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.

() Applicable only in case of minor dependants.

Note. - In case of a minor, the guardian should sign the claim on behalf of the minor in the following words below his signature : …………………………….
…………………………………………….………………………….(Name of the guardian) his/her ………………………………(relationship). 

*