FORM 25: Claim for Permanent Disablement Benefit
[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 ___________________