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Employees’ State Insurance (General) Regulations, 1950

FORM 17: Dependants' or Funeral Benefit

[Regulations 79 and 95C]


Book No ___________

Serial No ____________                                                                           

Stamp of the dispensary

Name of the deceased insured person _________________________________ son/wife/daughter  of _______________

Insurance No ____________________

    I certify that in my opinion the above named deceased insured person died on the day of __________ 19 __,as a result of an injury. 55[I had been attending him/her for providing medical benefit before his/her death and I attended him/her for the last time on the _____ day of ___ 19___

Signature ___________

Insurance Medical Officer

(Rubber stamp or name in block letters)

Date ________

Any other remarks by the Medical   Officer _______________________

Employees'   State Insurance (General) Regulations, 1950 Back

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