Form-I

Application for Assistance under WBUWHSS

[See Clause-4(2) of the Scheme]

To

The Authorised Officer,

West Bengal Unorganised Sector Workers Health Security Scheme.

……………………………………………

……………………………………………

Sir,

I do hereby submit my claim for assistance under the scheme for Rs……………………

(Rupees ……………………………………………………………………….) as details bellow.

  1. Name of beneficiaries :
  2. Account No. under SASPFUW :
  3. Name of the nominee :
  4. Relationship with the deceased worker :
  5. Date of death :
  6. Cause of death :

SL

Assistance towards

Amount

A Assistance in case of ailments :  
1 Clinical Tests  
2 Cost of medicines  
3 Assistance for Hospitalization

From …………………………… to ………………………………..

 
B Assistance in case of death  
  Natural/Accidental  
C Any other (please specify)  
     
  Total  

 

(Necessary documents in support of the claim to be enclosed)

I undertake to refund entire amount or part thereof if my claim is found to be false.

 

Date:                                                                                        Signature of the applicant

(Beneficiary/nominee)

 

***********************************************************************

Download Form-I WORD File Click Here 

Download Form-I PDF File Click Here

***********************************************************************

SHRAMIK SATHI : 1800 103 0009 (Toll Free Help Line)

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