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Employees’ State Insurance (General) Regulations, 1950

FORM 27: Declaration and Certificate for Dependants' Benefit

[Regulation 107A]

Insurance No. of deceased/Insured   person ___________________________________________

    I, _______________ of (address)_______________, do hereby solemnly declare:-

*(1) that I have not married/re-married.

** (2) that I declare that I am still infirm.

***(3) that I have not attained the age of eighteen years and am continuing my studies in   _________________ fifteen years. 

Dated _____________                                        

Signature or thumb impression of the dependant

    Certified that _______ , son/ wife/ daughter of _______ is alive this day, the ___ day  of ____ ,19 ___ and that the declarations made above are true to the best of my knowledge and belief.

Date _____________

Signature _____________

Designation _____________

(Rubber stamp or seal of the attesting authority or person)

*Applicable only in case of female dependants.

** Applicable only in case of legitimate infirm son or legitimate or adopted unmarried inform daughter. The claim in such cases shall be accompanied, if required, by a certificate of a certified authority.

***Applicable only in case of minor dependants.

       -Strike out whichever is not applicable.

Note : (1) In the case of a minor, the guardian should sign the declaration on behalf of the minor, and add the following words below his signature

    (Name of minor) _____________________________ through

    (Name of guardian)_________________________________

Employees'   State Insurance (General) Regulations, 1950 Back

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