Dependantsâ Benefit - Claim Form for Periodical Payments
| Updated at | March 2010 |
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...
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