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FORM 27: DECLARATION AND CERTIFICATE FOR DEPENDANTS' BENEFIT

Regulation 107A

Insurance No. of deceased/Insured person

___________________________________________

I, _______________ of (address)_______________, do hereby solemnly declare:-

(1) that I have not married/re-married.

(2) that I declare that I am still infirm.

(3) that I have not attained the age of eighteen years and am continuing my studies in _________________ fifteen years.

Dated _____________

Signature or thumb impression of the dependant

Certified that _______ , son/ wife/ daughter of _______ is alive this day, the ___ day of ____ ,19 ___ and that the declarations made above are true to the best of my knowledge and belief.

Date _____________

Signature _____________

Designation _____________

(Rubber stamp or seal of the attesting authority or person)

Applicable only in case of female dependants.

Applicable only in case of legitimate infirm son or legitimate or adopted unmarried inform daughter. The claim in such cases shall be accompanied, if required, by a certificate of a certified authority.

Applicable only in case of minor dependants.

-Strike out whichever is not applicable.

Note : (1) In the case of a minor, the guardian should sign the declaration on behalf of the minor, and add the following words below his signature

(Name of minor) _____________________________ through

(Name of guardian)_________________________________

 

 

 

 

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