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Claim for Permanent Disablement Benefit

Document Cited in Related
Vincent
Updated atMarch 2010

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...

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