శనివారం, సెప్టెంబర్ 17, 2011

(FORMAT FOR APAT BANDU)

ANNEXURE – E
(FORMAT FOR APAT BANDU)
THE NEW INDIA ASSURANCE COMPANY LIMITED
PROFORMA DOCUMENT FOR CLAIMS SETTLEMENT IN CASE OF ACCIDENTAL DEATH
DISTRICT:
DATED:
DETAILS OF THE DECEASED: -
1. Name
2. AGE:
3. ADDRESS
H.No.
Street
Locality
Village/Town
Mandal
District.
4. Father’s / Husband’s Name:
5. Annual Income of the Deceased’s family
6. Traveling from
Details of Accident: -
1. Date and time of accident
2. Place of Accident
3. Cause of Accident
4. Vehicle Registration number
5. Route Number in case of APLRTC DISTINATION.
6. FIR
Starting Point
(Compulsory and copy should be enclosed)
Police Station:
Town:
District
//Attested//
Mandal Revenue Officer.
7. Post Mortem
(Compulsory and copy should be enclosed)
8. Name and designation
Of the official who conducted the enquiry of death.
9. Date on which verification made
Details of Receipt of Relief
1. Name
2. Age
3. Relation to the deceased
4. Amount of relief given
a. Name
Age
Relation to the deceased
Amount of relief given
b. It is hereby confirmed that
i. The annual income to the family of the deceased person
ii. The death is account of road accident
iii. The relief has been paid to the legal heirs of the deceased after due verification
iv. Proper enquiries have been made in respect of the details furnished.
//Attested//
Mandal Revenue Officer.
Documents enclosed:
a. Death certificate compulsory to be enclosed
b. FIR and final investigation report compulsory to be enclosed
c. Panchanama
d. Post –Mortem report compulsory to be enclosed.
e. Certification from District Revenue Officers about beneficiaries families annual income (Compulsory to the enclosed)
f. Copy of relief sanction order from Government (Compulsory to be enclosed)
g. Copy of acquittance order of disbursal of exgratia by Government of Andhra Pradesh (Compulsory to be enclosed)
CERTIFIED THAT AS PER THE DETAILS GIVEN ABOUT AN AMOUNT OF
Rs._______________WAS DISBURSED PLEASE ARRANGE TO REIMBURSE THE SAME.
DISTRICT COLLECTOR
//ATTESTED/
MANDAL REVENUE OFFICER.
OFFICE OF THE MANDAL
MANDAL REVENUE OFFICE
MANDAL:
DATE:
FORM.10
(SEE RULE 10)
GOVERNMENT OF ANDHRA PRADESH
Village:
Certificate of Death caused under Section 17 of the Registration of Birth and Death Act 1960.
Registration No: Date:----------------------
1. Name
2. Sex
3. Date of Death
4. Place of Death
5. Name of the Father
6. Name of the Mother
Date:
Place:
MANDAL REVENUE OFFICER

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