To receive dependant’s benefit, the nominee of an insured person must submit a declaration-cum-certificate in this format, along with their June and December claims.
The certificate must be signed by one of the following:
- An officer of the Revenue, Judicial, or Magisterial Department
- A Municipal Commissioner
- A Workmen’s Compensation Commissioner
- The Head of a Gram Panchayat, under the official Panchayat seal
- An MLA or MP
- A Gazetted Officer of the Central or State Government
- A member of the ESIC’s Regional Board or Local Committee
- Any other authority the concerned Branch Manager considers appropriate