fofu-iz:i&16

vkfJr fgrykHk dkfyd lank;ksa ds fy, nkok

deZpkjh jkT; chek fuxe
¼fofu;e 83d½

e`r chekÑr O;fDr dk uke -------------------------------------------------------------------------------- chek la[;k---------------------------------

eSa ----------------------------------------------------------------------------------------------------- tks mDr uke ds e`r chekÑr O;fDr
dk@dh ----------------------------------------------------------------------------- gwa ¼ukrsnkjh½ mldk vkfJr gksus ds dkj.k ---------------------
---------------- ls --------------------------------------------------- rd dkykof/k ds y, vkfJr fgrykHk dk nkok djrk gw¡@djrh gw¡A
ns; jde dk lank;] eq>s euhvkMZj ls@'kk[kk dk;kZy; esa udn@pSd ls fd;k tk,A
eSa ;g Hkh ?kks"k.kk djrk@djrh gw¡ fd&
*¼1½ eSaus vHkh rd fookg*@iqufoZokg ugha fd;k gS ¼dsoy vkfJr efgyk dh n'kk esa ykxw½A
*¼2½ eSa 18 o"kZ dh vk;q dk ugha gqvk gwaW ¼vo;Ld iq#"k@efgyk vkfJrtu ds ekeys esa ykxw½A
*¼3½ eSa vHkh Hkh f'kfFkykax gwaA
¼dsoy /keZt@nÙkd* f'kfFkykax iq=k ;k /keZt@nÙkd* vfookfgr f'kfFkykax iq=kh dh n'kk esa ykxw ftUgksaus 18 o"kZ
dh vk;q izkIr dj yh gSA ,sls ekeyksa esa nkoksa ds lkFk fofufnZ"V izkf/kdkjh dk izek.k&i=k Hkh ;fn vis{kk dh tk,]
rks Hkstk tk,xkA

rkjh[k--------------------------------
**nkosnkj ds gLrk{kj ;k
vaxwBs dk fu'kku
orZeku irk----------------------------------------------------
--------------------------------------------------------------------
nkosnkj@laj{kd dk uke lkQ v{kjks esa ;k
** laj{kd ds gLrk{kj ;k vaxwBs dk fu'kku
----------------------------------------------------------------
vo;Ld vkfJrtu dk uke
ds }kjk ----------------------------------------------------
¼laj{kd dk uke½
---------------------------------------------------------------
vo;Ld ds lkFk ukrsnkjh
*tks ykxw u gks mls dkV nsaA
**o;Ld vkfJrtu }kjk fd, x, nkos ds ekeys esa ykxwA
***vo;Ld vkfJrtu }kjk fd, x, nkos ds ekeys esa ykxwA
[d-jk-ch- ¼dsUnzh;½ fu;e] 1950 ds fu;e 58 dks Ñi;k ns[ks]a
 REG. FORM-16
CLAIM FOR PERIODICAL PAYMENTS OF DEPENDANTS’ BANEFIT

EMPLOYEES' STATE INSURANCE CORPORATION

(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 _________________.

by money order.
The amount due may be paid to me __________________________________
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 depen-
dant).
*(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 or Thumb-impression
of the Claimant
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]