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Form 23

This document contains a life certificate form for permanent disability benefits from the Employees' State Insurance Corporation. The form requires information such as the insured person's name and insurance number. It must be signed and stamped by an authorized attesting authority, such as a government officer, to certify that the permanently disabled person is still alive. Making false statements to obtain benefits is punishable by law.

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4K views1 page

Form 23

This document contains a life certificate form for permanent disability benefits from the Employees' State Insurance Corporation. The form requires information such as the insured person's name and insurance number. It must be signed and stamped by an authorized attesting authority, such as a government officer, to certify that the permanently disabled person is still alive. Making false statements to obtain benefits is punishable by law.

Uploaded by

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

org

EMPLOYEES STATE INSURANCE CORPORATION


REG. FORM - 23 (To be submitted along with claim of June & December) LIFE CERTIFICATE FOR PERMANENT DISABLEMENT BENEFIT (Regulation 107)

Insurance No. of Permanently disable person *Certified that Sh./Smt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . w/s/d/ of . . . . . . . . . . . . . . . . . is alive this . . . . . . . . . . . . . . . . . day of. . . . . . . . . . . . . . . . . 20. . . . . . . .

Signature . . . . . . . . . . . . . . . . . . . . . . . . . Name in Block letter of Signing Claimant. Date . . . . . . . . . . . . . . . . . .................................. Designation with Rubber Stamp/ Seal of the Attesting Authority

Important:

Any person who makes a false statement or misrepresentation 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.

*This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmens Compensation Commissioner; or (iv) the Head of gram Panchayat under the official seal of the Panchayat, or (v) an M.L.A./M.P.; or (vi) A Gazetted Officer of the Central/ state Govt. or (vii) a member of the Regional Board/Local Committee of the ESIC; or (viii) any other authority considered appropriate by the Branch Manager concerned.

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