FORM 25A : FUNERAL EXPENSES Regulation 95E CLAIM FORM Claim arising from the death on ____________ of (insured person)_____ aged ____ years son/wife/daughter of _____________ having Insurance No __________ and last employed as __ son/wife/daughter of _________________ by __________________ (name of last employer). I_____________ (name of claimant) son/ wife/ daughter of ______ aged ___ years being the eldest surviving member of the family of the deceased insured person, whose particulars are given above declare that I incurred an expenditure of Rs _________ necessary for the funeral of the said deceased person and claim funeral expenses of the amount of Rs _____ I____________________________ (name of the claimant) son/wife/daughter of _______ aged _____ years declare that the deceased insured person whose particulars are given above did not have a family/was not living with his family at the time of his/her death and that I actually incurred an expenditure of Rs ______________ on the funeral of the deceased insured person and claim funeral expenses of the amount of Rs ______ Signature or thumb impression of the claimant Address __________________________ Date _____________ 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) Strike out whichever is not applicable. This certificate is to be given by (i) an officer of Revenue, Judicial or Magisterial Departments of Government; or (ii) a Municipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (v) the Head of the Gram Panchayat under the official seal of the Panchayat; or (v) the employer of the deceased insured person, or (vi) any other authority approved by the appropriate Regional Office. Notes: 1. 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. 2. In case of a minor, the guardian should sign the claim on behalf of the minor, and add the following words below his signature. (Name of the minor) through _____________ (Name of the guardian) his/her _____________(relationship) | 
