Download ESIC REG. FORM -15

As per ESIC Regulation 80 Submission of claim for dependants’ benefit

(1)     A claim for dependants’ benefit shall be submitted to the appropriate [branch office] by post or otherwise in [Form 15] by the dependant or dependants concerned or by their legal representative or, in case of a minor, by his guardian, and such claim shall be supported by documents proving—

(i)      That the death is due to an employment injury;

[(ii) That the person claiming is a dependant entitled to claim as provided in rule 58 of the Employees’ State Insurance (Central) Rules, 1950.]

(iii)  The age of the claimant;

(iv)  the infirmity of the dependant claiming to be infirm within the purview of [rule 58 of the Employees’ State Insurance (Central) Rules, 1950] by a certificate of such medical or other authority as the Director General may, by a general or special order specify in this behalf.

PROVIDED that where the appropriate regional office is satisfied about the bona fides of the applicant or about the truth of the facts relating to any of the matters mentioned above, one or more of the documents may be dispensed with.

(2)     The following may be accepted as proof of age—

(a)     Certified extract from an official record of births showing the date and place of birth

and father’s name;

(b)     Original horoscope prepared soon after birth;

(c)     certified extract from baptismal register;

(d)     certified extract from school record showing the date of birth and father’s name;

(e)     Such other evidence as may be acceptable to the appropriate Regional Office in the

circumstances of a particular case.

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