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  • Form 16

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    This document is a claim form for periodic payments of dependents' benefits from the Employees' State Insurance Corporation. The form collects information such as the name and insurance number of the deceased insured person, the claimant's relationship to the deceased, the period for which benefits are being claimed, and a declaration that the claimant is eligible such as not being remarried (for a female) or being under 18 or infirm (for dependents). The claimant or guardian must sign the form, along with their present address and relationship to the minor if claiming on their behalf.

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    This document is a claim form for periodic payments of dependents' benefits from the Employees' State Insurance Corporation. The form collects information such as the name and insurance number of the deceased insured person, the claimant's relationship to the deceased, the period for which benefits are being claimed, and a declaration that the claimant is eligible such as not being remarried (for a female) or being under 18 or infirm (for dependents). The claimant or guardian must sign the form, along with their present address and relationship to the minor if claiming on their behalf.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    394 views1 page

    Form 16

    Uploaded by

    hdpanchal86
    This document is a claim form for periodic payments of dependents' benefits from the Employees' State Insurance Corporation. The form collects information such as the name and insurance number of the deceased insured person, the claimant's relationship to the deceased, the period for which benefits are being claimed, and a declaration that the claimant is eligible such as not being remarried (for a female) or being under 18 or infirm (for dependents). The claimant or guardian must sign the form, along with their present address and relationship to the minor if claiming on their behalf.

    Copyright:

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    Download as PDF, TXT or read online from Scribd
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    org

    EMPLOYEES STATE INSURANCE CORPORATION


    REG. FORM 16 CLAIM FOR PERIODICAL PAYMENTS OF DEPENDANTS BENEFIT (Regulation 83-A) Name of the deceased Insured Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ins. No. . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , being the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . of the (relationship) above-named deceased Insured Person and also being his/ her dependant, do hereby claim Dependants Benefit for the period from . . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . The amount due may be paid to me by money order In cash/by cheque at Branch Office I also declare that *i) I have not married*/ re-married, so far (Applicable only in case of a female dependant). *ii) I have not attained the age of 18 years (Applicable in case of minor male/female dependant) *iii) I am still infirm. (Applicable only in case of a legitimate/ adopted* infirm son or a legitimate/adopted* unmarried infirm daughter who has attained the 18 yrs. of age. The claim to be accompanied, if required, by a certificate of specified authority).

    Date . . . . . . . . . . . . . . . **Signature or Thumb-impression of the Claimant Present Address . . . . . . . . . . . . . . . .............................. Name in Block letter of Claimant/Guardian. or ***Signature/ Thumb-impression of the Guardian for . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (name of the minor Dependant) through . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (name of the Guardian) his/ her . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (relationship with the Minor) *Please strikeout whichever is not applicable. **Applicable in the case of a claim by a major Dependant. ***Applicable in the case of a claim for a minor dependant.

    [Please refer to Rule 58 of the ESI (Central) Rules 1950]

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