(Regulation 83-A)
Name of the deceased Insured Person _________________________Insurance number No._____________ I ______________________________being the___________________ of the above- named deceased
(relationship)
Insured Person, and also being his/her dependant, do hereby claim Dependant’s Benefit for the period from ……… to ………
The amount due may be paid to me by money order_________ In cash/by cheque at Branch Office. I also declare that –
*I) I have not married/remarried so far
(Applicable only in case of a female dependant). *II) I have not attained the age of 18 years
(Applicable in case of a minor male/female dependant). *III) I am still infirm.
(Applicable only in case of a legitimate/ adopted* infirm son or a legitimate/adopted* unmarried infirm daughter who has attained the 18 yrs. of age. The claim to be accompanied, if required, by a certificate of specified authority).
Date ……… **Signature or thumb-impression of the claimant Present address ………. ………
Or
***Signature/Thumb-impression of the Guardian For _______________________________ (Name of the minor Dependant)
Through ___________________________ ( name of the Guardian)
His/her____________________________ ( relationship with the Minor)
* Please strikeout whichever is not applicable.
** Applicable in case of a claim by a major Dependant. *** Applicable in the case of a claim for a minor dependant. [ Please refer to Rule 58 of the ESI (Central) Rules 1950]
Annexure VII ESIC-40 (See paras P.6.28.1 et seq.)
DEPENDANTS’ BENEFIT 1. Name of dependant____________
_______________________________
4. Name of guardian___________ ________________________________
7. (a) Identification mark of the dependant_______________
8. Date of review_____________
2. Date of birth_________________ 5. Date of commencement of benefit
___________________________
(b) Dated initials of the Branch Manager
9. Date of termination of benefit (in case of minor)
3. Relationship to the deceased insured person________________ 6. Rate of benefit ________________ Name of deceased insured person Date
BENEFIT PAYABLE INITIALS BENEFIT PAYMENT BENEFIT
TERMINATED Due date for next declaration Remarks From day and month To day and month No. of days Amount of benefit Calculated by Checked by Passing day and month Initials Payment day and month Schedule sheet No. Sl. No.
How & date
Insurance No. Employer’s Code No. Date of employment injury Reference to the decision received from Regional Office Full rate of benefit Entered by Checked by
Annexure VIII (See para P.6.33.1) FORM 24 (to be submitted along with claim for June & December)
DECLARATION & CERTIFICATE FOR DEPENDANTS’ BENEFIT EMPLOYEES STATE INSURANCE CORPORATION
(Regulation 107A)
Name of the deceased Insured Person_____________________________ Ins. No. ____________
I,__________________________, being the ______________________ of the above –named deceased Insured Person and also being his dependant, do hereby solemnly declare:-
*i) that I have not married/remarried so far. (to be given only by a female dependant)
*ii) that I have not yet attained the age of eighteen years.
( to be given only in respect of a minor male or female dependant) *iii) that I have attained the age of eighteen years but continue to be infirm.
(to be given by a legitimate/adopted infirm son or by a legitimate/adopted infirm daughter. Certificate as specified, to be attached, if required)
Present Address:_________________________________________________________________
Date……….. _________________________
Signature or thumb impression of the dependant
or
_____________________________ Name in Block letters Signature or thumb impression of the
of signing claimant. Guardian in case of a minor dependant
Name of the Minor __________________ Through __________________________ (name of the Guardian) His/her ___________________________ (relationship with the Minor) CERTIFICATE
** Certified that Shri/ Smt. Kumari _____________________________________w/s/d/ of ____________________________ is alive this day the______ day of ___________ 20 and that the declarations made above are true to the best of my knowledge and belief.
Date_______________ Signature_______________
Designation______________
• Strike out whichever is not applicable.
** This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department, or (ii) a Municipal Commissioner, or (iii) a Workmen’s Compensation Commissioner, or (iv) the Head of gram Panchayat under the official seal of the Panchayat, or (v) an M.L.A./M.P.; or (vi) A Gazetted officer of the Central / state Govt. or (vii) a member of the
Regional Board/Local Committee of the ESIC; or (viii) any other authority considered appropriate by the Branch Manager concerned.
IMPORTANT: Any person who makes a false statement or misrepresentation for the purpose of obtaining benefit, Name in Block letter and
Rubber Stamp or Seal of the Attesting Authority
Annexure IX (See para P.6.40) (BY REGISTERED POST)
REGIONAL OFFICE………..
EMPLOYEES' STATE INSURANCE CORPORATION
No……… Dated:……….
To
_______________________________ _______________________________ _______________________________
Sub: Review of dependants' benefit in respect of late………. in terms of Section 55A of the ESI Act, 1948
Dear Sir/Madam,
Kindly take notice that the Corporation has taken in hand the review of rates of dependants' benefit admissible to the dependants of the above-named deceased insured person. As a result, the existing rate of dependants' benefit may be got reduced/enhanced/stopped.
For this, if you have any objection to the proposed review, you are advised to file the same within 21 days of the issue of this letter. Please note that if no reply is received by………., it would be presumed that you have no objection for such review, and the matter will be dealt with as proposed above.
Yours faithfully,
Regional Director
Copy forwarded to the Manager, Branch Office ……….for information. He is requested to forward the objections, if any, submitted by any of the dependants of the deceased as early as possible. He is also advised to stop the payment of dependants' benefit with effect from………..
Annexure X (See para P.6.41) (BY REGISTERED POST)
REGIONAL OFFICE………..
EMPLOYEES' STATE INSURANCE CORPORATION
No……… Dated:……….
To
Shri/Smt._______________________ _______________________________ _______________________________
Sub: Review of dependants' benefit in respect of late……….
Dear Sir/Madam,
In continuation of this office letter of even number dated ……… on the subject noted above, I have to inform you that as a result of the review of dependants' benefit, the Corporation has decided to commence/continue/increase/reduce/discontinue the share of each person mentioned below :-
Name of Person Relationship to deceased
insured person New rate of benefit
Date from which payable
Shri/Smt ……….. your father/mother has been accepted as your guardian and he/she would receive payment of dependants' benefit on your behalf from the Branch Office.
Yours faithfully,
Regional Director
Copy forwarded to the Manager ……… Branch Office for information and necessary action. The date of birth of Shri/Smt./Kumari ………..…has been accepted as……….…….. .