Canada/India Agreement

Applying for an Indian insurance benefit under the Employees’ Deposit-Linked

Insurance Scheme
Here is some important information you need to consider when completing your application for Indian benefits.
If your deceased family member died while employed in India, and a claim for insurance has not previously
been made to the Employees’ Deposit-Linked Insurance Scheme (EDLI), this Agreement may help you
obtain a lump sum insurance payment from the EDLI.

Please ensure you sign the application. If you are signing with a mark, (for example: “X”) the signature of a
witness is required.

Your application must be supported by documentation. Please submit the documents requested. Failure to
complete the application and provide the requested documentation may result in delays in processing your
application.

Where original documents are specifically requested, originals must be submitted with your application. You
should keep a certified true copy of any originals you send us for your records. Some countries require
original documentation which will not be returned to you.

You may submit the original or a photocopy that is certified as true for any of the documents where originals
are not required. It is better to send certified copies of documents rather than originals. If you choose to send
original documents, send them by registered mail. We will return the original documents to you. We can only
accept a photocopy of an original document if it is legible and if it is a certified true copy of the original. Our
staff at any Service Canada centre will photocopy your documents and certify them free of charge. If you
cannot visit a Service Canada Centre, you can ask one of the following people to certify your photocopy:

Accountant; Chief of First Nations Band; Commissioner for Oaths; Employee of a Service Canada Centre
acting in an official capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of
Financial Institution; Medical and Health Practitioners: Chiropractor, Dentist, Doctor, Naturopathic Doctor,
Nurse Practitioner, Ophthalmologist, Optometrist, Pharmacist, Psychologist, Registered Nurse; Member of
Parliament or their staff; Member of Provincial Legislature or their staff; Minister of Religion; Municipal Clerk;
Official of a federal government department or provincial government department, or one of its agencies;
Official of an Embassy, Consulate or High Commission; Officials of a country with which Canada has a
reciprocal Social Security Agreement; Police Officer; Professional Engineer; Social Worker; Teacher,
University Professor.

People who certify photocopies must compare the original document to the photocopy, state their official
position or title, sign and print their name, give their telephone number and indicate the date they certified
the document.

They must also write the following statement on the photocopy: This photocopy is a true copy of the original
document which has not been altered in any way.

If a document has information on both sides, both sides must be copied and certified. You cannot certify
photocopies of your own documents, and you cannot ask a relative to do it for you.

Return your completed application, forms and supporting documents to:

International Operations
Service Canada
PO Box 2710 Station Main
Edmonton, Alberta T5J 2G4
CANADA

Version (2019-12-04)
Disclaimer:
This application form has been developed by external
sources in cooperation with Employment and Social
Development Canada. The content and language
contained in the form respond to the legislative needs
of those external sources.
 Deceased member's Canadian
Social Insurance Number: __________________________

~ off./ Mobile Number

<:TtITmsur/Clam I.D .

lItF.H 1It.f.t
FORM5IF
~ f.IItq ~ 1ftwn"~. 1978
THE EMPLOYEES' DEPOSIT- LINKED INSURANCE SCHEME, 1976

~ ~ iI"RT3rof1T~ om ~, ~ ~ ~ ~ t <IT \ffiif; ~ iI"RTom ~, ~ ~ amtCf; ~ ~

mol <lit ~ 1) ~ To be filled up separately by each claimant. In case the claimant is minor
EiRT ~ lffiI "Iffl ~,
it should be filled up by the guardian on hislher behalf. Where there are more than one minor the guardian should
claim in one Form on their behalf.

fbquft - ~ JmT CJit 'ff.l ~ m .~ CJit ~ ~ ,Note - Read the "Instructions" carefully before completing this
form
1. ~ ~ <liT fcm1Jr
The Particulars in respect of the deceased member
«t;) ~~<IiT~
(a) Name ofthe Deceased member

«g) fimT <liT 'Ill{ ("qfct <liT 0f11i ~ ~ ~ l!T'ffi "4)

(b) Father's Name (Husband's name in the case of married woman)

(tr) ~~~
(c) Date of Death (ddlmmlyyyy) I 1 11 1 11 1 1 I 1
~) ~ /~ <liT 'Ill{ Cl"lffiT ~ ~ 3lf.trol" "ijR m /
(d) Name and Address of the Factory !Establishment
where the member was last employed.

~)~M~~ at./<IiT. <Ii1'. ~~$off. IDffi off.

(e) Provident Fund Account No RO/Office Code Estt. Code No. NcNo.

I I I I
2. ~/~ <liT fcm1Jr/ Details of the claimant/guardian.

«t;) OfJ1!"/Name

«g) WI'I ~/ Date of Birth (ddlmrnlyyyy)

(tr) ~ ~ ~ ~/ Relation with the deceased

~ ~ <liT fcm"uJ Ifth e calmant

I· a guar d·ran, detalso
IS ·1 fth e mmor nomine eIh eir
~ <liT 'Ill{/Name of the minor ~ <liT ~ ~ ~ ~/Relationship ofthe
guardian with minor

.,fi/~/ Shn.lSmt. .

Claimant's Full Postal address (in block letters) ~/~/tlfct/~/ Dol S/o W/O Hlo .

.................................. JiR/Pin .

~ ~ ~/Signature of claimant f.t<J)qffi ~ ~/Signature of Employer

Form 5IF (www.epfindia.gov.in) Page 1 of4

4 ~ ~ cm ffit Mode of remittance:

~ ~ q;<ff ~ ~ 'fi.(~ ~/~)

iffl{f <lIT<IT ~ ~ <lIT<IT 'fi./
Tj ~ ~ if anmrr <lIT<IT ~"4;m
li~itl:lf'lq; 1Jm11f S.B Account no .
\iJT1?/ By account payees cheque! electronic mode
sent Direct for credit to my S.B. NC (Scheduled ~ q;J YIfIl/
Bank IPO) Under intimation to me Name of the Bank .

(~ "-lIM "$ ~/~ ~ 11fT~ 1Iftt. WRlIT/Branch .

~ ill\" Please attach a copy of
cancelled/blank Cheque) WRlIT
q;J WT mrr/ Full Address of the Branch .

~ <6 mTeR 3f~ ~/zy:! ~ ~ ~ q;J fuJR)

(Signature or Left/Right hand thumb impression of the claimant)

~~.
Advance Stamped Receipt

...........................................
~~ ~)cm~~~~~/~~~1!iflIh;m
~ imT ~
......................................................................................... ~ ~;j)1:rr"lit\iAT"Rl"ll <6 <'it! "I'(~ ~ mff"l'( Vf'lT <6 ~ >rJ1{f ~I

*Received a sum ofRs ('Rupees only)

from Regional Provident Fund Commissioner/Officer-in-charge of sub Regional Office by
deposit in my Saving Bank account towards the Employees' Deposit Linked Insurance benefit.

~ ~/ ~ 1 ~
~ <6 ~ <mft ~
6""RT 'lffi ~ \i!RT ~ ~
*The space should be left blank which shall be filled in ~
by Regional Provident Fund Commissioner/Officer Revenue
incharge ofS.R.O. Stamp

~ <6 ~ ~ "iIttl"/GiII~ <6 ~ q;J fuJR

Signature or LeftlRight hand thumb impression of the claimant

Form 5IF (www.epfindia.gov.in) Page 2 of4

 lI'fI1If-~/ Certificate
(f.\ltIlIm Jm 'RI' 'GIl1l To be furnished by the Employer)

1~ f<I>m Wffi t ~ ~;l ~~ ~/~ f.mr'I f<I>m ~I ~ ~ ~ <rT ~ if; ~ ~~ tl

Certifiedthat the claimant is has signed/thumb impressedbefore me. I declare that the above particulars are true to the best of
my knowledge.

2. ~fcl;mWffi~fcl;~q\)~~~~~q;f ~I
Certified that the member died on while in service.

3~<tRmiifcl;~~/~/~ .
mm ~ q\) ~ ~ ~ ~/~/~ om ~ 'lml
Certified that the Provident Fund accumulation of deceased employee, late Sh/Smt./Kumari .
..................................................... Ale. No were paid to ShrilSmt./Kumari

(i)
(ii)
(iii)

W >IT'<!~ if; ~ 'F"" ~ if; 'W!i<IR "!l'EiI cm ~ /~ "\!fa ~ I

(The employer of exempted Establishment shall send on attested copy of the nomination of the deceased employee)

~ q\) ~ if; ~ ~ 12 ~ it ~ 1lrn" if; 3Rf ~ ~ if; ~ ~ ri -.'j it'! f<t<R"I !Balance in Provident Fund at
the end of the month, proceeding the 12 months immediately proceeding the death of the member
~ ~ ~ ~ 1952" W mll ~ am 'ffi \iIf\//To be filled in by employee of establishment exempted under
EPF Scheme 1952.
~. "ff./ 1lrn"/ Month 3tmFI <t; GFrr ~1\Rq';t i!ITGI/ ~/ ~ffl/
S.No ~/ Both 'Il"'Rfi / Refund Interest Withdrawals Progressive
shares of of withdrawal Balance
Contribution
l.

2.
3.
4.
5.
6.
7.
8.
9.
10.
ll.
12.
~/Total

12 lIM q;r iiI'R? ~~it'!f . ~it'!~ .

Total of l2 Months Provident Fund Balance f . Average Balance ~ .

~ ~ ~ ~ ~ •. "IT'! 0l!.TT 'IG'flll)

Signature of the employer (Name & designation with official Seal)

~Date
#~ ~ ~ it q;rc ~ Delete, if not applicable

~ : 3lW >IT'<!~ if; ~ am ~ ~ 2 'ffi \ifAT ~ aft< W m'<f ~ if; ~ cm 'ff4t «R ~ ~ I

Note: The employer of un-exempted establishment should fill in the column 2 only and the employer of exempted
establishment should fill in the all columns.

Form 5IF (www.epfindia.gov.in) Page 3 of4

 (~ iIRlf<;rq <f; wWr ~
(For the use of Commissioner's Office)

q;fl\ 21-11/9 ~) 1 <ft.f.t m.n ~ ~ 1\ G\it ~ ~ ~ I

Entered in Form 21-N9 (Revised) 1 I.F. withdrawal Register

~.~~.
SSA

~<f;~
(Under r )

"T"fR >!G msm

P.!' No .

AccountNo .

~
Section .

........................................................
~ ~ ~ <CI~"T"fR ~~ 'Im<CI~ m.n~
~/~/~ <f; ~ le!; ~ 1\ \ijlff ~ ~ am <Cl\jffI;[ Wf1I; le!; >'i t I
Passed for payment for ~ ~ , ) and the
amount may be remitted for credit to the Saving Bank Account No in respect of
Sh.lSmt.lKumari maintained at (Bank)

~ ~I Accounts Officer
~I Date: .

$I; ~ 'ff ~ bRT "T"fR fcI;m 'l<IT I

Paid by inclusion in cheque No.

lIT.~~. ~~ X'l.3Tf. / el.3Tf

SSA SS A.CIR.C

Form 5IF (www.epfindia.gov.in ) Page 4 of4

 Write your Indian Mobile Number on top of form to get SMS alerts

EMPLOYEES’ DEPOSIT LINKED INSURANCE SCHEME 1976

FORM 5(IF)
FOR CLAIMING INSURANCE AMOUNT IN CASE OF DEATH OF MEMBER
(TO BE UTILIZED WHEN MEMBER DIES WHILE IN SERVICE)

(PLEASE MAKE SURE THAT YOU ARE USING THE APPROPRIATE

APPLICATION FORM AND INSTRUCTIONS DOWNLOADED FROM THE
‘INTERNATIONAL WORKERS’ TAB ON WWW.EPFINDIA.GOV.IN OR
WWW.EPFINDIA.COM OR BY VISITING THE SERVICE CANADA WEBSITE
(WWW.SERVICECANADA.GC.CA). INSTRUCTIONS FOR EACH COUNTRY MAY
VARY)
INSTRUCTIONS
WHO CAN APPLY?:

1. Members of family (Nominees) nominated under Employees’ Provident Fund (EPF) Scheme.
Please refer to paragraph 61 of the EPF Scheme 1952 along with paragraph 23 of the
Employees’ Deposit Linked Insurance (EDLI) Scheme 1976.
2. In case of no nomination, all members of family (except the major son, married daughters
having husband alive, and major son, married daughters having husband alive of the
deceased son of the deceased member.)
3. In case of no family, and no nomination, legal heir.
4. Guardian of a minor nominee/family member/legal heir.

GENERAL INSTRUCTIONS

1. The benefit under Employees’ Deposit Linked Insurance Scheme, 1976 is admissible to the
person(s) entitled to receive the Provident Fund accumulations of the deceased member only
if the member’s death occurred while in service.
2. The form should be submitted along with Form 20 (for claiming the Provident Fund dues and
Form 10 D/10C for Pension/Withdrawal Benefit as applicable) so that all the benefits under
the three Schemes may be processed.
3. All details should be written (printed) in BLOCK LETTERS and there should not be any
overwriting (cursive).

www.epfindia.gov.in Page 1 of 3
4. In caseswhere the deceased member was a married female, the Husband’s name should be
mentioned in Column 1 (b) of the form. EPF Account Number: The account number should
have the Region Code (two letters, Office Code (three letters code number (maximum 7
digits), extension (sub code, if any, maximum three characters) and account number
(maximum 7 digits).
The region codes have changed after creation of the multiple regions in some states,
namely Maharashtra, Tamil Nadu, Karnataka, West Bengal, Punjab, Gujarat, Andhra
Pradesh, Uttar Pradesh, Haryana and Delhi. To obtain the correct Region and Office
Codes, please visit Establishment Search facility provided in the following link for
Employees on EPFO’s website www.epfindia.gov.in or www.epfindia.com
5. Payment shall be made directly tothe Bank Account detailedby the claimant. A claimant may
either indicate his/her Indian Bank Account or the bank account maintained in his/her
country. However, it is clarified that the facility of payment to the Bank account of his
country is available to the International Workers and their beneficiaries coming from the
countries with whom India has an Agreement on Social Security
6. A copy of the claimants’ blank/voidcheque or a copy of the front page of thebank
accountwhich includes all the necessary bank account details and banking
institution’saddress should be enclosed with the claim form.

ATTESTATION OF THE CLAIM

In cases where a claimant of an ‘International Worker’ is applying for PF settlement while

he/she still resides in India, the application should be submitted through the employer with whom
the member was last employed. The employer will then forward the claim to concerned RPFC
after attestation and completing other formalities.
In cases where the claimant is applying for PF settlement from Canada, the form should be
filled by the applicant and submittedto Canadian liaision agency: Service Canada – International
Operations. The application form, as well as the necessary information required under the social
security agreement between Canada and India will then be transmitted to the EPFO office in
India to render a decision regarding your application.

In case the claimant is using a downloaded version of the form then all pages should be
signed by the claimant.
In case of a closed establishment whose Authorised Signatory/Employer is not available, the
claimants may forward the claim with banking details to the Canadian liaison agency: Service
Canada- International Operations.

www.epfindia.gov.in Page 2 of 3
 DOCUMENTS TO BE ENCLOSED
(a) Death certificate, in case the application is by the nominee/surviving family
members or their guardian/legal heirs after the death of the member or certification to
that effect by the liaison agency
(b) Guardianship certificate issued by a competent court of law, if the application is
preferred by a guardian other than the natural guardian of minor
member/nominee/family member/legal heir.
(c) A copy of the claimants blank/void cheque or a copy of the front page of the
bank accountwhich includes all the necessary bank account details and banking
institution’s address should be enclosed with the claim form.

www.epfindia.gov.in Page 3 of 3
 Canada/India Agreement

Documents and/or information required to support your application [5 IF] for an

Indian insurance benefit under the Employees’ Deposit-Linked Insurance Scheme

Complete the attached forms:

 Information required by the pension authorities in India to process your Indian benefit
application under the Employees’ Deposit-Linked Insurance Scheme

Originals or certified copies to be submitted:

 Death certificate

 Void cheque stamped by your bank containing the following information:

o Name and address of the account holder
o Details of bank account: branch number, institution number and account number

 Guardianship certificate if applying on behalf of a minor

Information required by the pension authorities in India to process
your Indian benefit application under the Employees’ Deposit-
Linked Insurance Scheme

1. Your full name if applying as a worker (including middle name(s), maiden

name and married name, if applicable), or the deceased’s full name if
applying as a survivor (including middle name(s), maiden name and married
name, if applicable):

________________________________________________________

2. Your Universal Account Number (UAN) or Indian Provident Fund Number if

applying as a worker, or the deceased’s Universal Account Number (UAN) or
Indian Provident Fund Number if applying as a survivor:

________________________________________________________

________________________________________________________

3. Your date of birth if applying as a worker, of the deceased’s date of birth if

applying as a survivor:

________________________________________________________
DD / MM / YYYY

4. Your phone number:

________________________________________________________

1
 5. Start and end dates of your employment if applying as a worker, or start and
end dates of the deceased’s employment if applying as a survivor, and name
and address of your employer if applying as a worker or the deceased’s
employer if applying as a survivor:

Start and end dates of employment

Name and address of employer
Start date End date

___________________________________
_________________ ________________
DD/MM/YYYY DD/MM/YYYY
___________________________________

___________________________________

___________________________________
________________ ________________
DD/MM/YYYY DD/MM/YYYY
___________________________________

___________________________________

___________________________________
________________ ________________
DD/MM/YYYY DD/MM/YYYY
___________________________________

___________________________________

___________________________________
________________ ________________
DD/MM/YYYY DD/MM/YYYY
___________________________________

___________________________________

___________________________________
________________ ________________
DD/MM/YYYY DD/MM/YYYY
___________________________________

___________________________________