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3 FORM - 9 CLAIM FOR BENEFIT FOR SICKNESSEMPLOYEES' STATE INSURANCE CORPORATION(Regulation 63 & 89-B)I_____ Insurance No. _____ s/w/d of_____ hereby claim Cash Benefit for period over leaf and state.(i)*That because of sickness/temporary disablement/sickness due to pregnancy/confinement/premature birth of child/ miscarriage. I have not been at work since _____.(ii)* I no longer claim to be sick/temporary diabled/sick due to pregnancy/confinement/ prematurebirth of child/miscarriage from _____ and I shall/did not take up any work forremuneration before that date.(iii)* I have not been in receipt of any wages for the days of leave/holiday (s).(iv)* I was not on strike during the period of certified abstention on account of sickness/temporarydisablement from _____to_____for which the benefit is desire payment in *cash at Branch Office / By Money or of claimantName in Block Letters _____Address _____Notes person who makes a false statement or misrepresentation for the purpose of obtaining benefitwhether for himself/some other person shall be punishable with imprisonment up to 6 months orwith a fine up to Rs.

4 2,000/- or with form should be completed and submitted WITHOUT DELAY to the appropriate Branch final certificate must be obtained before resuming out if not applicable.