Dependantsâ Benefit (Claim Form )
Updated at | March 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
-
………………………
-
………………………
-
………………………
-
………………………
*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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