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Form 18

This document is a claim form for dependents' benefits arising from the death of an insured person. The form collects information about the deceased insured person including their name, insurance number, and last employer. It then requests details about dependents making the claim such as their name, address, date of birth, relationship to the deceased, sex, marital status, and guardian if a minor. The form declares that the provided details are true and must be signed. An attesting authority must also certify the truth of the declarations.

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8K views

Form 18

This document is a claim form for dependents' benefits arising from the death of an insured person. The form collects information about the deceased insured person including their name, insurance number, and last employer. It then requests details about dependents making the claim such as their name, address, date of birth, relationship to the deceased, sex, marital status, and guardian if a minor. The form declares that the provided details are true and must be signed. An attesting authority must also certify the truth of the declarations.

Uploaded by

hdpanchal86
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as RTF, PDF, TXT or read online on Scribd
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FORM 18 DEPENDENTS BENEFIT [ Regulation 80] CLAIM FORM

Claim arising from the death on . of (insured person) son/wife/daughter of .. having Insurance No.. and last 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: Name and address of the dependant Date of birth or age Relationship with the deceased Sex Marital status Name of the guardian in case of a minor

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 abovenamed insured person: Name and address of the dependant Date of birth or age Relationship with the deceased Sex Marital status Name of the guardian in case of a minor

I / We declare that the particulars given above are true to the best of my / our knowledge and belief. Signature Present address 1. 2. 3. 4. * Certified that the declaration made above are true to the best of my knowledge and belief. Signature . Rubber stamp or seal of the attesting authority Designation . * This certificate is to be given by (i) an officer of the Revenue, Judicial or Magistrate Departments of Government; or (ii) a Municipal Commissioner, or (iii) a Workmens Compensation Commissioner; or (iv) the Head of the Gram Panchayat under the official seal of the Panchyat; or (v) any other authority approved by the appropriate Regional Office. Note : Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself or for some other person renders himself liable to prosecution.

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