BOCW Department

DIU

FORM V

EX-GRATIA FOR PERMANENT DISABILITY/CHRONIC DISEASES

Eligible Criteria:

An application in the prescribed Form-V along with supporting documents to the Member Secretary (BOCWWB) shall be made by the member of the fund. The Board may sanction an amount due to any reason below given:

Payment of Rs. 1,00,000/- in case of 100% permanent disability for any reason.
In case of Chronic Diseases the beneficiary may get self treatment or treatment for his/her dependents as indoor patients from any hospital and get medical expenditure incurred, reimbursed against expenses but not exceeding Rs. One Lakh in a year.
An Amount of Rs. 40,000/- will be given in case of Surgery,/Operation. (Other than operations related to maternity).

Submit*

Name of Applicant*

Name of Dependent*

Address of Applicant*

Relationship with Beneficiary*

Name of Beneficiary*

Date of Birth*

Age*

Gender*

Marital Status*

Mobile No.*

Aadhaar Number*

Temporary Address:

Address Line1*

Address Line2

Landmark*

Village/Town/City*

Taluka*

District*

State*

Pincode*

Permanent Address:

Address Line1*

Address Line2

Landmark*

Village/Town/City*

Taluka*

District*

State*

Pincode*

Loss Of Earning Capacity*

Date of 1st Subscription Amount*

Date of Last Subscription Amount*

Treatment Has Been Taken*
Government
Private

Period of treatment as patient in Government/ Private*

Name of Hospital*

Name of Doctor*

Hospital Contact No.*

Details Of Benefit:-

Details of benefits availed from this board earlier *

Details of benefits received, if any from Government or any other institution. For the said treatment*

Bank Details:

Bank Account Number*

Name Of Bank*

Name Of Branch*

IFSC Code*

(a) Upload Medical Certificate

(b) Upload Certificate of Cause For Disability

Submit*

EX-GRATIA FOR PERMANENT DISABILITY

DIU

EX-GRATIA FOR PERMANENT DISABILITY/CHRONIC DISEASES

Department Addresses

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