Claim for Permanent Disablement Benefit
I, ……………………………………………, s/w/d 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 money order/in cash at local office.
Date ………… Signature or thumb impression
Present Address ………………
ANOTHER FORM
I, ………………………………… s/w/d of ………………………………………
Insurance No. ……………… declare that, because of sickness/temporary disablement, I have not been at work since the date of last/first certificate sent to you.
I no longer claim to be sick/temporarily disabled ………… from ……… day of ……… 19………… and I shall/did not take up any work for remuneration before that day, I claim benefit accordingly. I desire payment in cash at local office/by money order.
Signature or thumb impression
Date ………… Local office ……………
Present Address …………………