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EOBI Form PE-0 Insured Person’s Invalidity Allowance Claim Form, under Regulation 3 of E.O.B. (Payment of Invalidity Allowance) Regulations, 1981

 PE-0

EMPLOYEES OLD-AGE BENEFITS INSTITUTION

 

Insured Person’s Invalidity Allowance Claim Form, under Regulation 3 of E.O.B. (Payment of Invalidity Allowance) Regulations, 1981.

 

Note:?The following document should be supplied with this form:

 

Attested Photo?copy of National Identity Card (both sides):

 

 

1. NAME ————————————————————————

 

2. FATHER’S/HUSBAND’S NAME ——————————————–

 

3. AGE/DATE OF BIRTH ——————————————————-

 

4. PRESENT ADDRESS  ——————————————————-

 

5. REGISTRATION No.

-

-

(ALLOTTED BY EOBI)

 

6. DATE OF JOINING THE EOB SCHEME ————————————

 

7. POSITION OF INSURABLE EMPLOYMENT ——————————

 

Sr. No.	Name and Address of Employer	Employer’s Registration No: (if available)	Period of Insurable Employment
1			From              To
2
3

 

TOTAL PERIOD OF INSURABLE EMPLOYMENT ………………

 

8. DATE OF SUSTAINING INVALIDITY———————————–

 

9. HOW AND WHERE INVALIDITY SUSTAINED ————————

 

10. MONTHLY WAGES (s) IMMEDIATELY BEFORE SUSTAIN? ——–

ING INVALIDITY:

 

 

(b) AFTER SUSTAINING INVALIDITY,

IF ANY ————————

 

 

11. IF UNEMPLOYED AT PRESENT, SINCE WHEN?———————–

 

 

12. DETAILS OF BENEFITS UNDER THE PROVINCIAL EM­PLOYEES SOCIAL SECURITY ORDINANCE, 1965, IF ANY, RECEIVED AFTER THE DATE OF SUSTAINING INVA­LIDITY

 

Sr. No.	Benefits	PERIOD	Amount Per Month(Rs.)
1. Sickness Benefit		From          To
2. Injury Benefit
3. Disablement Gratuity
4. Disablement Pension

 

 

DECLARATION

 

I, ——————————-, S/d, W/o, D/c——————————————–

Do hereby solemnly declare and ` verify that the information given above is true and correct to the best of my knowledge and that no material facts have been concealed ———————————————————–

 

Place——————-

Signature/Thumb Impression of Insured Person

 

Date. ————————–

 

Two specimen signatures/Thumb impressions for affixing in the Allowance Book

 

CERTIFICATE OF THE EMPLOYER

 

Certified that Mi./Mrs./Miss————————————— S/o, W/o, D/o ———————— is/was an Insured Person of this estabii3hment and that the details furnished by him/her in this form are correct L:) the best of our knowledge and information.

 

It is further certified that the invalidity was not sustained by him/her as a result of occupational disease or an accident arising out of or in the course of his/her employment.

 

It is further confirmed that:

 

(a) He/She is not employed with us after sustaining the invalidity : or

 

(b) He/She continues to be employed with us after sustaining the invalidity and is being paid Rs. ————————– as wages instead, of Rs. ————-     which was being paid to him/her immediately before sustaining the invalidity.

 

Place———————– seal of the             establishment

 

Date.———————-

 

—————————–

Authorised Signature of Employer

 

E.O.B.I, Registration No.———–

 

MEDICAL CERTIFICATE TO BE COMPLETED BY THE ATTENDING PHYSICIAN

 

Certified that Mr./Mrs./Miss. ———————————————————————S/o, W/o, D/o. —————————————- whose Particulars are given is this form is/was under my treatment since —————————— He/She is/was suffering from the ——————– which has ——————– caused ———— per cent permanent incapacity for work in him/her. In my opinion, his/her invalidity nay continue for a period of at least ——————– months/days from the date of sustaining invalidity.

 

Date—————— Office Seal —————–

——————

Signature

 

Name (in Block Letters)——————–

Address ————————————

Regn. No. ———————————-

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<< Employees’ Old Age Benefits (Payment of Invalidity Allowance) Regulations, 1981Employees’ Old-Age Benefits (Determination of Complaints, Questions and Disputes) Regulations, 1980 >>

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