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Employees’ State Insurance (General) Regulations, 1950

FORM 25: Claim for Permanent Disablement Benefit

[Regulation 76A]

    I, ________________ son/wife/daughter of _____________ Insurance No __ having been declared  as permanently disabled by the Medical Board/Appeal Tribunal/claim permanent disablement benefit accordingly, for the period from _______________ to ____________

    The amount due may be paid to me/by in money order/cash at local office _________

Date ___________

Signature or thumb impression

Present address ___________________

Employees'   State Insurance (General) Regulations, 1950 Back

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