AUTHORIZATION LETTER TO CLAIM BENEFITS

GALORE GOLD and FASHION Dubai, United Arab Emirates Email: [email protected] ; Website:www.galoregoldfashion.com ” DISCOVER THE NEW YOU” AUTHORIZATION LETTER TO CLAIM BENEFITS I, (Name, Address, Phone Number), hereby notify to claim and receive by his/her presence on my behalf, all the money and benefits in case of my death. BENEFICIARY INFORMATION: First Beneficiary: Name Address Street City State Home Phone Email Date of Birth Relative Relation Spouse Child Parent Others Others In case not found First Beneficiary, Second Beneficiary: Others Name Address Street City State Home Phone Email Date of Birth Relative Relation Spouse Child Parent In case not found Second Beneficiary, Third Beneficiary: Name Address Street City State Home Phone Email Date of Birth Relative Relation Spouse Child Parent Upon notice of the death of the employee, the Plan Administrator generally begins gathering information for your claim. To process your claim, we must have a fully completed Claim Form from each beneficiary and other document as appropriate to the claim. You may use a photocopy of the Claim Form if there is more than one beneficiary. No original documents will be returned. Any person who knowingly and with intent to defraud company or other person files an application for company or statement of claim containing any fact material thereto may be subject to persecution for fraud. ______________________________ ______________________________ Full Name Signature 1|Page