Employees' State Insurance (General) Regulations, 1950
[Regulations 63 and 89B]
CLAIM FOR BENEFIT
I______________________ son/wife/daughter of ________________ Insurance No ____ declare that, because of sickness/temporary disablement, I have not been at work since the date mentioned in the first/last certificate sent to you.
23[I have not been in receipt of wages on account of leave, holidays. I was not on strike during the period of certified abstention for which benefit is claimed.]
I claim benefit accordingly. I desire payment in cash at local office/by money order.
Signature or thumb impression
Local office _______
Present address (if changed)___________
Notes: (1) Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself or for some other person renders himself liable to prosecution.
(2) This form should be completed and sent without delay to the appropriate local office.
(3) The insured person should obtain a final certificate before resuming work.