Form Ub1 – Fill Out and Use This PDF

National Insurance & Social Security Act, 1969

Application for Undrawn Benefit

Particulars of Deceased Insured Person

1. Name of deceased person:

2. National Insurance No.:

3.Address:

4.	Date of Birth:	D	M	Y	Date of Death: D M			Y

5.Cause of Death: …………………………….............................................................................................

6. Was the deceased in receipt of any benefit?

Yes No

7.Have you in your possession any uncashed payment vouchers issued in the name of the

deceased?

Yes No

If so, kindly return voucher/vouchers with this application

Particulars of Applicant

8. Name of Applicant:

9.Address:

10. Are you related to the deceased insured person?

Yes No

11.If you are, in what capacity? .............................................................................................................................

12.If not related, in what capacity are your making claim: Personal Representative , Administrator Legatee , Creditor

13. Did the deceased leave a Will?

Yes No

14.If Probate or Letter of Administration has been granted, state below the name(s) and address(s) of the Executor(s)/Administrator(s).

NameAddress:

…………………………………………… ……..…………………………………………………….

…………………………………………… ……………………………………………….…………..

…………………………………………… ………………………………….………………………..

15.State the name and address of the person who has paid or is liable to pay the cost of the funeral expenses of the deceased insured person

Name:

Address:

16.I, ....................................................................................................... declare the above statement to be true to the best of my knowledge and belief.

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The documents listed below should be attached to this application.

1.A copy of the deceased person’s certificate of death.

2.A copy of the marriage certificate (if applicant is wife).

3.Uncashed payment vouchers issued to and in the name of the deceased.

4.A copy of Probate (if one has been granted).

For Official Use

General Manager,

I have examined the above claim and the attached documents and hereby certify that the claim

submitted by	is in order for payment of
Benefit for the period	to
Kindly approve payment.
Prepared by:	Approved by:
Signature	General Manager
Date:	Date:

To be completed by Benefits

Record of Payment

Date	B.P.V. No.	Type of Benefit	Amount
................................	................................... ..................................................		...................................

Prepared by: ......................................................

Checked by ......................................................

Form UB1

Research & Planning Dept

(Revised July 2010)