[Regulation 76A]

    I, ________________ son/wife/daughter of _____________ Insurance No __ having been declared  as permanently disabled by the Medical Board/Appeal Tribunal/claim permanent disablement benefit accordingly, for the period from _______________ to ____________

    The amount due may be paid to me/by in money order/cash at local office _________

Date ___________

Signature or thumb impression

Present address ___________________