REG. FORM -15 CLAIM FORM FOR DEPENDANT'S BENEFIT EMPLOYEES' STATE INSURANCE CORPORATION (Regulation 80) Name of the deceased Insured Person__________________________________Ins. No.__________________ S/W/D of_________________________________________________Date of Death______________________ Last employed as ___________________________________________by______________________________ I/We the following, being dependants of the above named deceased insured person, hereby claim and accordingly apply for dependant's benefit on account of his/her death. Name of the dependant Sex Age or year of birth Marital status Relationship with the deceased Present Address Name of guardian in case of a minor 1 2 3 4 5 6 7 I/We declare that the particulars given above are true to the best of my/our knowledge and belief. I/We also declare that to the best of my/our knowledge & belief, there is no other dependant entitled to claim Dependant's Benefit in r/o the death of the above-noted deceased I.P., save and except those mentioned above. Signature*{1_____________________ 2_____________________ 3_____________________ 4_____________________ ATTESTATION** Certified that the declarations, as made above are true to the best of my knowledge and belief. Name in Block letter and Signature________________________ Rubber Stamp or Seal of The Attesting Authority Designation______________________ * All major dependants' should sign individually and the guardian to sign in case of a minor dependant. ** This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department of Government, or (ii) a Muncipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (iv) the Head of the gram Panchayat under the official seal of the panchayat, or (v) M.L.A./M.P.; or (vi) Gazetted Officer or (vii) a member of the Local committee/Regional Board of the ESI Corporation, or vii) any other authority considered appropriate by the Branch Manager IMPORTANT : Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or some other person, commits an offence punishable with imprisionment for a term which may extend up to six months or with a fine up to Rs. 2,000/or with both fofu- iz:i&15 vkfJr izlqfo/kk ds fy, nkok iz:i deZpkjh jkT; chek fuxe ¼fofu;e 80½ e`rd chekÑr O;fDr dk uke----------------------------------------------------------------------------------- chek la[;k------------------------------- iq=k@iRuh@iq=kh-------------------------------------------------------------------------------------------e`R;q dh rkjh[k------------------------------------------ eSllZ------------------------------------------------------------------------------}kjk--------------------------------------- ds :i esa vafre ckj fu;ksftrA eSa@ge tks mi;qZDr e`r chekÑr O;fDr dk@ds vkfJr gwa@gS] mldh e`R;q dh ckcr vkfJr izlqfo/kk ds fy, nkok djrk gwa@djrs gSaA vkfJr dk uke fyax vk;q ;k tUe dk o"kZ oSokfgd izkfLFkfr e`rd ds lkFk ukrsnkjh orZeku irk vo;Ld dh n'kk esa laj{kd dk uke 1 2 3 4 5 6 7 eSa@ge ?kks"k.kk djrk gw¡@djrs gSa fd mi;qZDr of.kZr esjh@gekjh loksZÙke tkudkjh vkSj fo'okl ds vuqlkj lgh gSaA eSa@ge ;g Hkh ?kks"k.kk djrk gw¡@djrs gSa fd mi;qZDr of.kZr fooj.k esjh@gekjh loksZre tkudkjh vkSj fo'okl ds vuqlkj mi;qZ of.kZr vkfJrtuksa dks NksM+dj mi;qZ e`r chekÑr O;fDr dh e`R;q ij vkfJrtu fgrykHk dk nkok djus ds fy, dksbZ vU; vkfJrtu ugha gSA { 1_____________________ 2_____________________ gLrk{kj¹ 3_____________________ 4_____________________ vuqizek.ku¹¹ izekf.kr fd;k tkrk gS fd Åij dh xbZ ?kks"k.kk,a esjh loksZÙke tkudkjh vkSj fo'okl ds vuqlkj lgh gSA vuqizek.ku izkf/kdkjh dk gLrk{kj------------------------------------------------------ uke lkQ v{kjksa esa vkSjjcM+ dh eksgj ;k eqnzk inuke------------------------------------------------------- ¹ lHkh O;Ld vkfJrtuksa dks O;f xr :i ls gLrk{kj djus pkfg, vkSj vo;Ld vkfJrtu ds ekeys esa laj{kd ds gLrk{kj gksus pkfg,A ¹¹ ;g izek.k&i=k ¼1½ ljdkj ds jktLo] U;kf;d ;k eftLVsªV foHkkx ds fdlh vf/kdkjh ;k ¼2½ uxj ikfydk vk;q ( ;k ¼3½ deZdkj izfrdj vk;q ( ;k ¼4½ xzke iapk;r ds eqf[k;k }kjk iapk;r dh 'kkldh; eqnzk yxk djds ;k ¼5½ fo/kk;d @lkaln ;k ¼6½ jktif=kr vf/kdkjh ;k ¼7½ d-jk-ch- fuxe ds {ks=kh; lfefr@LFkkuh; lfefr ds lnL; ;k ¼8½ lacaf/kr 'kk[kk izca/kd }kjk vuqeksfnr dksbZ vU; mi;qDr izkf/kdkjh }kjk fd;k tk,xkA egRoi.kwZ % dksbZ O;fDr] pkgs vius fy, ;k vU; O;fDr ds fy,] izlqfo/kk vfHkizkIr djus ds iz;kstu ls feF;k dFku ;kegRoiw.kZ % feF;k O;ins'ku djsxk vius dks vfHk;kstu ds fy, ftEesnkj Bgjk;sxk vFkkZr 2000@& #i;s rd dk tqekZuk ;k 6 eghus rd dk dkjkokl ;k nksuksa gh naM fn, tk ldrs gSaA
