Scribd
Upload
1K views

Form 15

This document is a claim form for dependent benefits from the Employees' State Insurance Corporation of India. It requires information such as the name and insurance number of the deceased insured person, their relationship to the claimant, and declarations that the claimant is a legal dependent and that all dependents are listed. The form must be signed by all major dependents and attested by an authorized witness such as a government official.

Uploaded by

hdpanchal86
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
1K views

Form 15

This document is a claim form for dependent benefits from the Employees' State Insurance Corporation of India. It requires information such as the name and insurance number of the deceased insured person, their relationship to the claimant, and declarations that the claimant is a legal dependent and that all dependents are listed. The form must be signed by all major dependents and attested by an authorized witness such as a government official.

Uploaded by

hdpanchal86
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

www.esicoimbatore.

org

EMPLOYEES STATE INSURANCE CORPORATION


REG. FORM 15 CLAIM FORM FOR DEPENDANTS BENEFIT (Regulation 80) Name of the deceased Insured Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ins. No. . . . . . . . . . . . . . . S/W/D of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Death . . . . . . . . . . . . . . . Last employed as . . . . . . . . . . . . . . . by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I/we the following, being dependants of the above named deceased Insured Person, hereby claim and accordingly apply for dependants benefit on account of his/ her death: Name of the dependant 1. Sex 2. Age or year of birth 3. Marital status 4. Relationship with the deceased 5. Present Address 6. Name of guardian in case of a minor 7.

I/We declare that the particulars given above are true to the best of my/our knowledge and belief. I/We also declare that to the best of my/our knowledge & belief, there is no other dependant entitled to claim Dependents Benefit in r/o the death of the above-noted deceased I.P., save and except those mentioned above. 1. . . . . . . . . . . . . . . . . . . Signature* 2. . . . . . . . . . . . . . . . . . . 3. . . . . . . . . . . . . . . . . . . 4. . . . . . . . . . . . . . . . . . . ATTESTATION** Certified that the declarations, as made above are true to the best of my knowledge and belief. Signature . . . . . . . . . . . . . . . . . . Designation. . . . . . . . . . . . . . . . . .

Name in Block letter and Rubber Stamp or Seal of the Attesting Authority

* All major dependants should sign individually and the guardian to sign in case of a minor dependant. **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 Workmens Compensation Commissioner, or (iv) the Head of the Gram Panchayat under the official seal of the Panchayat, or (v) M.L.A./ M.P., (vi) Gazetted Officer, or (vii) a member of Local Committee/Regional Board of the ESI Corporation, or (viii) any other authority considered appropriate by the Branch Manager. Important: Any person who makes 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.

You might also like