Employees' State Insurance (General) Regulations, 1950
FORM 14: Sickness or Temporary Disablement or Maternity Benefit for Sickness
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 no longer claim to be sick/temporarily disabled, from ______________ and I shall / did not take up any work for remuneration before that day.
I claim benefit accordingly. I desire payment in cash at local office/by money order.
Present address (if changed)_____
Signature or thumb impression
Local office ________
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.