Employees' State Insurance (General) Regulations, 1950
CLAIM FOR PERIODICAL PAYMENTS
Name of the deceased insured person ____________________
Insurance No ___________________________
I ,______________________________ (state relationship with the deceased) ________ of the above named insured person, being his dependant, claim dependants' benefit for the period from _______ to _______
The amount due may be paid to me (by money order) / (in cash at the local office)
I declare that I have not married/ remarried so far (*)
I certify that I have not attained the age of eighteen years and am continuing my studies in _______________ fifteen years**
I declare that I am still infirm***
Signature or thumb impression of the claimant
Present address ____________
*Applicable only in case of female dependants.
** Applicable only in case of minor dependants.
*** Applicable only in case of legitimate infirm son or legitimate or adopted unmarried infirm daughter. The claim in such cases shall be accompanied, if required, by a certificate of specified authority.
Note: In case of a minor, the guardian should sign the claim on behalf of the minor, and the following words below his signature ________________________
(Name of the minor) through _____________________
(Name of the guardian) his/her ____________________________________ relationship.