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  • Dependents' Benefit (Regulation 83A) Claim For Periodical Payments

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    jacobpm2010
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    The claimant is submitting Form 18A to claim periodic payments of dependents' benefits from the deceased insured person's insurance policy. The claimant provides their name and relationship to the deceased, the insurance number, and requests payment for the specified period either by money order or cash. The claimant also declares whether they have married/remarried, are continuing their studies if a minor, or are still infirm. A guardian must sign on behalf of a minor claimant.

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    acccident

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    form18A

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    The claimant is submitting Form 18A to claim periodic payments of dependents' benefits from the deceased insured person's insurance policy. The claimant provides their name and relationship to the deceased, the insurance number, and requests payment for the specified period either by money order or cash. The claimant also declares whether they have married/remarried, are continuing their studies if a minor, or are still infirm. A guardian must sign on behalf of a minor claimant.

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    © All Rights Reserved
    Download as RTF, PDF, TXT or read online from Scribd
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    12 views1 page

    Dependents' Benefit (Regulation 83A) Claim For Periodical Payments

    Uploaded by

    jacobpm2010
    The claimant is submitting Form 18A to claim periodic payments of dependents' benefits from the deceased insured person's insurance policy. The claimant provides their name and relationship to the deceased, the insurance number, and requests payment for the specified period either by money order or cash. The claimant also declares whether they have married/remarried, are continuing their studies if a minor, or are still infirm. A guardian must sign on behalf of a minor claimant.

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    © All Rights Reserved
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    FORM 18 A

    DEPENDENTS 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 form .. 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 continuing my studies in ..
    fifteen years**
    I declare that I am still infirm***
    Date : .

    Signature or thumb impression of the claimant


    Present address

    *
    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 fopllowing words below
    his signature
    (Name of the minor) through
    (Name of the guardian) his / her relationship.

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