Employees' State Insurance (General) Regulations, 1950
FORM 24A: Maternity Benefit after The Death of an Insured Woman Leaving Behind The Child
CLAIM FOR BENEFIT
Claim arising from the death on _______________________ of (insured woman)__________ wife/daughter of _______________ having Insurance No _____________ and last employed by ____________
I_________________________ (state relationship if any with the deceased _____ of the above named insured person, being her nominee/ her legal representative (she having left no nominee) claim maternity benefit for the period from ______ to ________
I declare that the deceased insured person died on ___________ leaving behind the child who is still alive/who also died on _____________
The amount due may be paid to me to money order or in cash at the Local Office.
I declare that the particulars given above are true to the best of my knowledge and belief.
Signature or thumb impression of the claimant
Present address _____________________
*Certified that the declarations made above are true to the best of my knowledge and belief.
(Rubber stamp or seal of the attesting authority)
*This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Departments of Government; 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 (v) the employer of the deceased insured person; or (vi) any other authority approved by the appropriate regional office.
Note: Any person who makes a false statement or representation for purpose of obtaining benefit whether for himself or for some other person renders himself liable to prosecution.