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DECLARATION & CERTIFICATE FOR …

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(To be submitted along with claim of June & December)REG. FORM 24DECLARATION & CERTIFICATE FOR DEPENDANTS BENEFITEMPLOYEES STATE INSURANCE CORPORATION.(Regulation 107-A)Name of the deceased Insured Person __________________________ Ins. ________________________________________ being the _____________________ of the above-nameddeceased Insured Person and also being his dependant, do hereby solemnly declare :-* (i)that I have not married*/remarried so far. (to be given only by a female dependant).*(ii)that I have not yet attained the age of 18 years.

(To be submitted along with claim of June & December) REG. FORM 24 DECLARATION & CERTIFICATE FOR DEPENDANTS™ BENEFIT …

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