3.2 (Name of the Insured) who

died on (Date of the Death) is my, (Delete whichever word inapplicable)

Bearing NIC No do hereby Solemnly, Sincerely and Truly Declare and

Affirm as follows;

(Pe~onalAddress) ------------------------------------------------

3.1 ---------------------------------------------------------- I (Full Name) residing at

3. Declaration of the Applicant

Res 2.3 Telephone No: Office --------------------------

2.2 Name and Address of the Institution:----------------------------------------------

2.1 Post held: 2. Information of the Employment of the Insured died

Grama Niladhari Wasama :

OS Division 1.4 District:

1.3 Personal Address:

(Please attach a certified copy of the NIC)

1.2 National Identity Card No.

In Sinhala: ----------------------- --------

1. Information en the insured died 1.1 Name in full Ven/Mr/Mrs/Miss

(Go through the instructions carefully before filling the application)

Ref.No .

Date: ..

Claim No.NITF/D ..

For office use only

Insurance Cover on Personal Accident Death & Natural Death Claim form for Accidental Death & Natural Death.

Date Your No. My No.

Form No.42

NATIONAL INSURANCE TRUST FUND No. 97, Maradana Road, Colombo 10. Tel: 011- 4892617 Fax: 011-2333893

I scruitinizes the above particulars and certify the same to be correct. At the time of the death of the Insured his father/mother mentioned above depended on him. Accordingly I certify that the above particulars are true and correct.

5. Confirmation of Declaration (Delete whichever word inapplicable) (Applicable to all individuals died irrespective of marital status)

Signature of Declarant Date: .

I certify that the information given above are true and correct.

S/No. Name Relation to N.l.C. Date of Marital Employment the insured No. Birth Status

died

4.3 As the Insured at the time of his/her death had not made a Last Will or written Probate, please take action to pay the accidental/natural death benefits of the deceased made available by the National Insurance Trust Fund to the following Inheritors.

S/No. Name Relation to N.l.C. Date of Marital Employment the insured No. Birth Status

died

4.2 At the time of the death of the Insured he/she had written the Last Will or a Probate. Accordingly given below are information on individuals being legal claimants to his/her property at the time of the death of the Insured.

D Details of inheritors who are legally entitled to receive benefits: 4.1 Number of Inheritors legally entitled to receive benefits: 4.

• Legal wife/husband • Father/Mother (If the Insured died unmarried) • I am the child appeared under 3.1 above as Applicant and information on all the other

children are indicated overleaf (if both wife/husband of the Insured have been died or divorced)

When a Last Will is available • (As per Public Administration Circular No.12/2005) entitlements are distributed among

Inheritors who are considered as dependents of the Insured died from among Inheritors included in the Last Will.

If unmarried • To mother/father of the Insured (who were dependents of the Insured)

If married • To husband/wife and unmarried and unemployed children less than 21 years of age. • If husband/wife of the insured who died have not been alive or divorced to his/her unmarried

and unemployed children less than 21 years of age.

Entitlements are paid,

When a Last Will is not available

• In every instances where photo copies of the relevant documents/certificates are submitted they should have been certified by Head of the Department.

Instructions for completing the application:

• Duly completed application should be sent to the NITF within 06 months from the Date of Death.

Signature Name Post

(Official Frank essential} Date: .

......................................................................................................................................................................................

As per his/her personal file, the information on his/her spouse and children are correct. As he/she died unmarried the information given by his/her mother/father are true and correct.

Any comments, if any .

I certify that at the time of death of the Insured on whose, particulars are indicated at 1 above, he had not been subjected to a dismissal from service or retirement. The Declaration confirming the right of obtaining insured sum of the late .. Is hereby recommended and submitted.

6. To be filled by Head of the Department (Delete whichever word inapplicable)

Official frank of Divisional Secretary

Signature of Divisional Secretary

Date: .

Official frank of Grama Niladhari

Signature of Grama Niladhari

I certify that the above particulars are true and correct.

Date: .

....................................................................................................................................................................... Any special comments, If any .

• If the Insured died by a road accident, certified copy of his/ her Driving Licence only in case the insured drove the vehicle at the time of the accident.

Please obtain from Relevant Magistrate

Court I Register

• Certified photo copy of the report to be submitted by the police to the Magistrate (Police Investigation Report should not be a statement made by the Police)

• Certified photo copy of detailed report of the Coroner • Certified photocopy of the Post Mortem Report to bes ubmitted through Health

Gen 42 form

If Insured death has been caused by an accident, the following reports too should be submitted in addition to the above documents:

If the Insured died unmarried, the following documents have to be submitted in addition to the documents under Part 'a' above.

• Certificate submitted by the Head of the Institution that the Insured has died unmarried. • Certified photo copies of National Identity cards of father and mother of the Insured died. • Certified photo copies of birth certificates of father and mother of the Insured died. • If father or mother of the Insured died is not alive a certified photo copy of his/her death

certificate. • Photo copies of bank accounts of mother and father of the deceased (not be a joint account)

When the Insured has been died married the following documents too have to be submitted in addition to documents referred to under Part 'a'.

• Certified photocopy of the Marriage Certificate. • Certified photo copy of the Birth Certificate of the Applicant (Wife/Husband)

• Certified photo copies of Birth Certificates of children (photo copies of Birth Certificates of all children should be submitted.)

• A photocopy of bank account of the applicant (should not be a joint account) • Photo copies of NSB bank accounts opened in respect of teenage if any (should not be accounts

opened in postal bank branches.) • Photo copies of bank accounts of children between the 18-21 years of age. • Certified photocopy of the National Identity Card of the applicant. • If husband/wife of the insured died has also not been alive, certified photo copy of his/her

death registration certificate. • A certified copy of the court verdict if husband/wife of the insured has been legally divorced at

the time of the death of the insured. • Certificate issued by the Grama Niladhari to the effect that the insured has no children.

Documents to be submitted along with the application a. If the Insured died • Certified photo copy of the Birth Certificate • Certified photocopy of the N.l.C. • Certified photo copy of the Certificate of the Registration of Death • Last drawn salary particulars (certified by Head of the Department) • Certificate of the Accountant(along with cheque details) to the effect that insurance premium

has been recovered continuously since 2012 • Certificate of Head of the Department on places of work served. • Affidavit signed on Rs.25 stamp if changes of names appeared on documents/files of the

Insured died/Applicants/Dependents.

TMTypewritten textnnNote :- Please Note to obtain the payment of this death claim, you shall not be paid any amountas tax, stamp duty or as document charges to national insurance trust fund or to any other instituteor person.