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Form 14

The document is a claim form for permanent disablement benefits from the Employees' State Insurance Corporation of India. It provides fields for the claimant to fill in their insurance number and signature, as well as the period for which they are claiming benefits. The claimant is requesting that payment of their due benefits be made by money order or in cash at the local branch office.

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2K views1 page

Form 14

The document is a claim form for permanent disablement benefits from the Employees' State Insurance Corporation of India. It provides fields for the claimant to fill in their insurance number and signature, as well as the period for which they are claiming benefits. The claimant is requesting that payment of their due benefits be made by money order or in cash at the local branch office.

Uploaded by

hdpanchal86
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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www.esicoimbatore.

org

EMPLOYEES STATE INSURANCE CORPORATION


REG. FORM 14

CLAIM FOR PERMANENT DISABLEMENT BENEFIT


(Regulation 76-A) I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s/w/d/ of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Insurance No. having been declared as permanently disabled by the Medical Board/

Medical Appeal Tribunal/ Employees Insurance Court, claim Permanent Disablement Benefit accordingly for the period from . . . . . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . . The amount due may be paid to me by money order/ in cash at Branch Office

.......................... Signature or Thumb impression of the Claimant Name in block letters . . . . . . . . . . . . . . . . . . . . . . . . . . . . and Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................... . Dated . . . . . . . . . . . . . . . . . . Important: Any person who make a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs.2,000/-, or with both.

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