FENERAL EXPENSES CLAIM FORM EMPLOYEES'
STATE INSURANCE CORPORATION
(Regulation 95-E)
Claim arising
out of death on .................. of ................. s/w/d of
.................. aged .....................
years, having Insurance No.
.............. and last employed as ................. by M/s.
................... Code No. ....................
I
....................................... s/w/d of
.......................................... aged ........................ years
declare :
**(i) that I am the
eldest surviving member of the family of the deceased Insured Person, whose particulars are furnished
here-in-above, and that I actually incurred an expenditure of Rs. .................... (Rupees
.................. only) necessary for the funeral
of the said deceased person.
or
**(ii) that the deceased Insured Person, whose
particulars are furnished there-in-above, did not have a family / was not
living with his family at the time of his / her death and that I actually
incurred an expenditure of Rs. .................... (Rupees
...............only) on the funeral of the deceased Insured Person.
Accordingly, I do hereby claim funeral expenses for the
amount of Rs. ....................................
(Rupees .............................only)
Date : Name
in Block Letters ...................................................................................
Signature /
Thumb-impression
ATTESATION
of the Claimant
*** Certified that the
declarations, as made here-in-above, are true to the best of my knowledge and
belief.
Name
in Block Letters
and Rubber Stamp or Seal of the Attesting Authority
Signature ...................................
Designation ............................... Date
.............................................
*Delete either (i) or (ii), which may not be applicable in
the case.
**This
certificate is to 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 M.L.A./M.P.; or (v) A Gazetted Officer of the Central/State Govt./Member of the Local Committee / Regional Board; or (vi) any other authority considered as 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 for 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.]
Note : In the case of a minor, the guardian should sign the claim form on bahalf
of the minor and then add the following below his/her signature: —
........................................
(Name of
the Minor) Through .....................
(Name of
the Guardian) his/her
............................
(Relationship with the Minor)
