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FORM 25: CLAIM FOR PERMANENT DISABLEMENT BENEFIT

Regulation 76A

I, ________________ son/wife/daughter of _____________ Insurance No __ having been declared as permanently disabled by the Medical Board/Appeal Tribunal/claim permanent disablement benefit accordingly, for the period from _______________ to ____________

The amount due may be paid to me/by in money order/cash at local office _________

Date ___________

Signature or thumb impression

Present address ___________________

 

 

 

 

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