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Form 12 – EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS,1950

FORM 12: Sickness or Temporary Disablement Benefit

[Regulation 63 read with section 63]

CLAIM FOR BENEFIT

    I_________________________ son/wife/daughter of _____________ Insurance No ______ hereby state that because of sickness/temporary disablement, I have not been at work since _______________________

    I have not been in receipt of wages for leave holidays.

    FURTHER, I state that I was not on strike during the period of certified abstention on account of sickness/temporary disablement, i.e. from ________ to ________ for which benefit is claimed.

    *I no longer claim to be sick/temporary disabled from take up any work for remuneration before that date.

    I claim, benefit, accordingly, I desire payment in cash at local office/by money order.

Present employer (if changed)_______________ department ______________________ present address ( if changed) ________________________________________________________

Date ______________________

Signature or thumb impression

Local office ____________

Accident case only

    Date, time and place of accident ________________________________________________ if a notice of the accident had not been given to the employer state briefly, on a separate paper how the accident happened.

Date ______________

Signature or thumb impression

* Delete whichever is not applicable.

Notes: 1. Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself or for some other person renders himself liable to prosecution

2. This Form should be completed and sent without delay to the appropriate local office.

3. A final certificate must be obtained before resuming work.]

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