Employees’ State Insurance (General) Regulations, 1950
FORM 27: Declaration and Certificate for Dependants' Benefit
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.
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.
(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)_________________________________