Dependants’ Benefit (Claim Form )

Updated atMarch 2010

CLAIM FORM

Claim arising from the death on ………… of (insured person) …………….. s/w/d of ………… having Insurance No. …………………… and that 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.

Nature of the dependants

Date of birth or age

Relationship

With the deceased

sex

Marital

status

Name of the

guardian in case of a minor

1

2

3

4

5

6

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.

Names and address of the dependants

Date of birth or age

Relationship

With the deceased

sex

Marital

status

Name of the

guardian in case of a minor

1

2

3

4

5

6

I/We declare that the particulars given above are true to the best of

my/our knowledge and belief.

Signatures Present Addresses

  1. ………………………

  2. ………………………

  3. ………………………

  4. ………………………

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

Rubber stamp or seal of

the attesting authority

Signature ………..……

Designation .............…

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

* This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Departments of Government; or (ii) a Municipal...

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