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FORM 26: CERTIFICATE FOR PERMANENT DISABLEMENT BENEFIT

Regulation 107

Insurance No. of permanently disabled person

___________________________________

Certified that ____________ son/wife/daughter of ____________________ is alive this day the ___________ day of________19___

Date _____________

Signature _____________

Designation _________

(Rubber stamp or seal of the attesting authority or person)

 

 

 

 

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