Form 24a – EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS,1950

FORM 24A: Maternity Benefit after The Death of an Insured Woman Leaving Behind The Child

[Regulation 89A]

CLAIM FOR BENEFIT

    Claim arising from the death on _______________________ of (insured woman)__________ wife/daughter of _______________ having Insurance No _____________ and last employed by ____________

    I_________________________ (state relationship if any with the deceased _____ of the above named insured person, being her nominee/ her legal representative (she having left no nominee) claim maternity benefit for the period from ______ to ________

    I declare that the deceased insured person died on ___________ leaving behind the child who is still alive/who also died on _____________

    The amount due may be paid to me to money order or in cash at the Local Office.

    I declare that the particulars given above are true to the best of my knowledge and belief.

Signature or thumb impression of the claimant

Present address _____________________

Dated ____________

    *Certified that the declarations made above are true to the best of my knowledge and belief.

Signature _____________

Designation _____________

(Rubber stamp or seal of the attesting authority)

*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 Workmen’s Compensation Commissioner; or (iv) the Head of Gram-Panchayat under the official seal of the Panchayat; or (v) the employer of the deceased insured person; or (vi) any other authority approved by the appropriate regional office.

Note: Any person who makes a false statement or representation for purpose of obtaining benefit whether for himself or for some other person renders himself liable to prosecution.

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