Dependant’s Benefit Deed Format

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 dependantsDate of birth or ageRelationship With the deceasedsexMarital statusName of the guardian in case of a minor
123456
      
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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 dependantsDate of birth or ageRelationship With the deceasedsexMarital statusName of the guardian in case of a minor
123456
      

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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