FORM 18: DEPENDANTS' 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 above- named 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. Signatures Present address 1______________ __________________ 2______________ __________________ 3______________ __________________ 4______________ __________________ Certified that the declarations made above are true to the best of my knowledge and belief. Signature _________ Designation ________ Rubber stamp or seal of the attesting authority 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. 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. | 
