Professional Documents
Culture Documents
HYDERABAD
MEDICAL AID APPLICATION FORM
v Cancer v Brain tumor v Heart Ailments, v Paralysis treatment v Hysterectomy
v Trauma treatment (Serious wounds/injuries caused dut to accidents)
Affix
Applicant
Photo
: ...............................................................................................
2. S/o, W/o
: ...............................................................................................
3. Residential Address
: ............................................................................................................
: ............................................................................................................
with Address
............................................................................................................
5. Designation
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
...........................................................................................................
Date :
Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.
Date :
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :
: ...............................................................................................
2. S/o, W/o
: ...............................................................................................
3. Residential Address
: ...........................................................................................................
............................................................................................................
: ...............................................................................................................
: ...........................................................................................................
: .............................................................................................................
: .............................................................................................................
with address
.........................................................................................................
10. Whether the applicant availed this benefit earlier : Yes / No
11. Date on which the application is made : ............................................................................................................
Date :
Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.
Date :
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :
: ...............................................................................................
: .....................................................................
: ........................................................................................................
4. Residential Address
: ........................................................................................................
6. Designation
: ........................................................................................................
: ........................................................................................................
6. Designation
: ........................................................................................................
: ........................................................................................................
: ........................................................................................................
9. Date of death
: ........................................................................................................
Date :
Date :
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :
: ...............................................................................................
2. S/o, W/o
: ...............................................................................................
3. Residential Address
: ...........................................................................................................
6. Designation
: ...........................................................................................................
: .............................................................................................................
: .............................................................................................................
5. Designation
: ................................................................................................................
: ..........................................................................................................
: ................................................................................................................
8. Date of Accident
: ................................................................................................................
9. Nature of Accident
: .............................................................................................................
Date :
Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.
Date :
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :
: ...............................................................................................
2. W/o, D/o
: ...............................................................................................
3. Residential Address
: ................................................................................................................
6. Designation
: ..........................................................................................................
: ............................................................................................................
: ..........................................................................................................
5. Designation
: ............................................................................................................
............................................................................................................
: ..............................................................................................................
8. Date of Delivery
: ..........................................................................................................
: .........................................................................................................
of the hospital
.........................................................................................................
Yes / No
Date :
Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.
Date :
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :
Affix
Applicant
Photo
: ...............................................................................................
2. S/o, W/o
: ...............................................................................................
3. Residential Address
: ................................................................................................................
...........................................................................................................
: ..............................................................................................................
: ............................................................................................................
: ............................................................................................................
8. Date of operation
: ............................................................................................................
: .............................................................................................................
the hospital
: .............................................................................................................
Yes / No
Date :
Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.
Date :
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :
Affix
Applicant
Photo
: ...............................................................................................
2. S/o, W/o
: ...............................................................................................
3. Residential Address
: ...............................................................................................................
..........................................................................................................
: ..............................................................................................................
.........................................................................................................
5. Designation
: ..............................................................................................................
: ...............................................................................................................
: ..........................................................................................................
: ............................................................................................................
9. Nature of Disability
: ............................................................................................................
: .........................................................................................................
: ...............................................................................................
Date :
Certified that the applicant is not covered under E.S.I. or any such facility or benefit provided by the management.
Date :
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :
Affix
Applicant
Photo
: ...............................................................................................
2. S/o, D/o
: ...............................................................................................
3. Residential Address
: ........................................................................................................
........................................................................................................
: .........................................................................................................
.......................................................................................................
5. Designation
: .........................................................................................................
: ...........................................................................................................
: .........................................................................................................
: ........................................................................................................
: ............................................................................................................
: ..........................................................................................................
Date :
Certified that the applicant is not covered under E.S.I. or any such facility or benefit provided by the management.
Date :
Signature of the Employer with seal
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :
Affix
Applicant
Photo
: ...............................................................................................
2. S/o, W/o
: ...............................................................................................
3. Residential Address
: .................................................................................................................
: ...............................................................................................................
with Address
...............................................................................................................
5. Designation
: ...................................................................................................................
: ...............................................................................................................
: ....................................................................................................................
: ....................................................................................................................
: .....................................................................................................................
Yes / No
Date :
Certified that the monthly salary / wages of the above wokrer is Rs.
(Rupees...........................................
..................................................................................)
Date :
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :
Affix
Applicant
Photo
: ...............................................................................................
. .........................................................................................................
4. Residential Address
: ...........................................................................................................
........................................................................................................
: ............................................................................................................
: ............................................................................................................
: ............................................................................................................
: ...........................................................................................................
: ...........................................................................................................
3) Postmortem Report
Date :
Certified that the applicant is not covered under E.S.I. or any such facility or benefit provided by the management.
Date :
OFFICE USE
RC No.............................
Date :........................
RC No.............................
Date :........................
Date :
Date :