Dependants’ Benefit – Claim Form For Periodical Payments 156 - Legal Draft
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Dependants’ Benefit - Claim Form for Periodical Payments
Form 18A
(See Regulation 83A)
(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 ()
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
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.
() 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).
...................................................................................(Name of the guardian) his/her ....................................(relationship).
*