Scribd
Upload
889 views1 page

Form 24

This document is a form from the Employees' State Insurance Corporation for claiming dependents' benefits. It requires the claimant to declare their relationship to the deceased insured person and provide details confirming their eligibility such as not being remarried (for female dependents) or being under 18/infirm (for minor/infirm dependents). The form must be signed by the claimant and certified by an authorized attesting authority to verify the declarations.

Uploaded by

hdpanchal86
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
889 views1 page

Form 24

This document is a form from the Employees' State Insurance Corporation for claiming dependents' benefits. It requires the claimant to declare their relationship to the deceased insured person and provide details confirming their eligibility such as not being remarried (for female dependents) or being under 18/infirm (for minor/infirm dependents). The form must be signed by the claimant and certified by an authorized attesting authority to verify the declarations.

Uploaded by

hdpanchal86
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

www.esicoimbatore.

org

EMPLOYEES STATE INSURANCE CORPORATION


REG. FORM 24 (To be submitted along with claim of June & December) DECLARATION & CERTIFICATE FOR DEPENDANTS BENEFIT (Regulation 107 A) Name of the deceased Insured Person . . . . . . . . . . . . . . . . . . . . . . . . . . Ins. No.

I . . . . . . . . . . . . . . . . . . . . . . . . . . ., being the . . . . . . . . . . . . . . . . . . . . . . . . . . . of the abovenamed deceased Insured Person and also being his dependant, do hereby solemnly declare: *i) *ii) *iii) that I have not married/ remarried so far. (to be given only by a female dependant) that I have not yet attained the age of eighteen years. (to be given only in respect of a minor male or female dependant) 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: _____________________________________________________________________ ........................... Signature or thumb impression of the dependant or Name in Block letters Of signing claimant. .................................... Signature or thumb impression of the 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 . . . . . . . . . . . . . . . . . . of 20 and that the declarations made above are true to the best of my knowledge and belief.

Date: . . . . . . . . . . . . . . . . . .

Date . . . . . . . . . . . . . . . . . .

Name in Block letter and Rubber Stamp or Seal of the Attesting Authority

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 Workmens 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, whether for himself or some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs.2,000/- or with both.

You might also like