FORM 18A: DEPENDANTS' BENEFIT Regulation 83A CLAIM FOR PERIODICAL PAYMENTS Name of the deceased insured person ____________________ Insurance No ___________________________ I ,______________________________ (state relationship with the deceased) ________ of the abovenamed insured person, being his dependant, claim dependants' 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 I certify that I have not attained the age of eighteen years and am continuing my studies in _______________ fifteen years I declare that I am still infirm Signature or thumb impression of the claimant Present address ____________ Dated ______ Applicable only in case of female dependants. Applicable only in case of minor 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. Note: In case of a minor, the guardian should sign the claim on behalf of the minor, and the following words below his signature ________________________ (Name of the minor) through _____________________ (Name of the guardian) his/her ____________________________________ relationship. | 
