Dependants’ Benefit
Dependant’s Benefit Deed Format
CLAIMFORM
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 Commissioner; or (iii) a Workmen’s Compensation Commissioner; or (iv) the Head of the Gram Panchayat under the official seal of the Panchayat; or (v) any other authority approved by the appropriate Regional Office.
Dependant’s Benefit Deed Format
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