FORMS
Form scheme no. 2
HEALTH
ANNEXURE ‘A’
DOCTOR’s CERTIFICATE
This is to certify that Shri/Smt. ______husband/wife of ______whose signature/LTI is appended below has undergone sterilization operation successfully on ______at ______(Name of the Medical Institution). I recommended that monetary compensation of Rs.200/- may please be paid to him/her from the Beedi Iron Ore Manganese Ore and Chrome Ore, Limestone and Dolomite Mine and Cine Workers Welfare Funds of the Labour Welfare Organisation.
Signature ______
Signature/LTI Name of the Doctor ______
(Seal)
Shri/Smt. ______
ANNEXURE „B‟
Application Form for payment of Monetary Compensation for Sterilization.
1. Name of the applicant: Shri/Smt. ______
2. Wife/Husband of : Shri/Smt. ______
3. Identity Card No. ______
4. No. of living children of the applicant.
5. Date of sterilization.
6. Name of Medical Institution where sterilization operation was conducted.
(i) It is requested that Monetary Compensation @ Rs.200/- may be sanctioned to me for having undergone sterilization operation at ______.
(ii) A certificate issued by the aforesaid medical institution is enclosed herewith.
(iii) I undertake that I shall refund the said compensation if at any stage it is proved that it is false claim.
______
Signature/Thumb impression of the
Applicant/Iron Ore, Limestone and
Dolomite/ Cine Workers.
Date: ______
Countersigned by Employer.
Scheme no. 3
ANNEXURE-I
APPLICATION FORM FOR THE PAYMENT OF LUMP SUM GRANTS OF Rs.1000/- TO FEMALE WORKERS UNDER THE MATERNITY BENEFIT SCHEME FOR FEMALE BEEDI, IMC, LSDM AND CINE WORKERS.
1. Name of the applicant :
2. Address :
3. Wife/Daughter of :
4. Identify Card No. :
5. Date of delivery :
It is requested that the lump sum grant of Rs.1000/- may kindly be sanctioned to me. Following certificates are enclosed:-
i)Birth Certificate of the Child born.
ii) Certificate to the effect that I am a beedi, IMC, LSDM and Cine Worker.
The certificate shows that I have been a beedi, IMC, LSDM and Cine Worker for
at least six months before the delivery.
iii) Certificate to the effect that the benefit is being claimed for the first/second time.
I understand that I shall refund the said amount if it is proved that it is a false claim.
Dated: ______Signature/Thumb impression of the Applicant
Recommendation of the Medical Officer Incharge of the nearest dispensary of the Labour Welfare Organisation.
Medical Officer Incharge
ANNEXURE-II
This is to certify that Smt. ______wife/daughter of Shri ______is a beedi/IMC/LSDM/Cine Worker. She is employed with ______as on date and has been engaged in beedi making/working as IMC/LSDM/Cine Workers for the last ______year(s) and ______month(s).
** According to her statement which is enclosed. Her employer as per her statement has refused to issue her the employment certificate. Her Identity Card No. is ______.
______
Signature of Employer/Gazette Officer of the Labour Welfare Fund Organisation/medical Officer Incharge
of the nearest dispensary of the Labour Welfare Organisation.
Dated ______
** This may be deleted in case the employer signs the certificate.
Scheme no.4
Annexure-I
FORM „A‟
Application form for financial assistance for Heart surgery or allied treatment.
To
The Welfare Commissioner,
Labour Welfare Organisation,
------
Sir,
I hereby apply for financial assistance for undergoing Heart Surgery or allied treatment in ______mention the name of the hospital where the Medical Officer, Labour Welfare Organisation, has recommended the treatment. In this connection, I submit my particulars as under:-
1. Name of the Applicant in Full:
(In Block Letters)
2. Name and address in full of the
Mine/Beedi establishment/Beedi
Contractor/Agent
3. The date of his/her employment
and total continuous service.
4. Designation or the nature of
His/Her Employment.
5. His/Her monthly salary/wages
(Excluding bonus)
6. (a) Identity Card No. in case
ofBeedi/Cine Workers.
(b) „B‟ Register No. in case of
Mine Worker.
Signature of Mine/Beedi/Cine worker
Name:
Place:
Date:
Certificate by the Mine Manager/owner and in case of beedi worker by owner of Establishment/Contractor/Agent.
It is certified that Shri/Smt/Kum ______is employed in this mine/Beedi Establishment by me as ______continuously with effect from ______and information furnished by him/her as above are correct.
Signature:
Designation:
Name & Address of the Mine/Beedi
Management/Contractor.
Date:
Seal of the Mine/Beedi Establishment
COUNTERSIGNED BY THE owner/Manager of the Beedi Establishment if the worker is working under Contractor/Agent.
Date: OWNER/MANAGER
Name:
Designation:
Address:
CERTIFICATE OF THE MEDICAL OFFICER OF THE LWO.
Certified that I have carefully examined Shri /Smt/ Kumari ______
______and found him/her suffering from ______disease. In my opinion, his/her admission in the ______hospital which is recognized by the Govt. of ______is absolutely necessary for Kidney Transplantation or allied treatment.
His/Her Identity Card No. is ______/ „B‟ Register No. is ______
Signature:
Name:
Designation:
Name of the Dispensary/Hospital
Dated:
FORM „B‟
Application for grant of subsistence allowance from the Labour Welfare Organisation under the Scheme for Financial Assistance to Mine/Beedi/Cine workers suffering from heart diseases.
To
The Welfare Commissioner,
Labour Welfare Organisation.
Sir,
I hereby apply for financial benefits under the scheme for “financial assistance to mine/beedi and cine workers for ______I have undergone treatment for ______in ______(mention the name of the hospital where the treatment has been taken). I furnish my particulars as under: -
1. Name of the applicant in full:
2. Date of birth/Age:
3. Full postal/residential address
of the applicant
4. Full address of the hospital
where the applicant has undergone
treatment
5. The reference No. and date of the
letter from Welfare Commissioner
permitting Him/her to undergo
treatment in the above hospital.
6. Amount actually incurred by the
applicant for treatment
(Furnish the details with supporting
billsetc, each bill has to be countersigned
by the hospital authorities with seal
and full signature)
a. Hospital charges including diet etc. Rs.
b. Expenses for pre post operation
Check ups: Rs.
c. Charges for heat valve etc, which were required to be purchased from
hospital/market (prescription slips to be enclosed)
Total :Rs.
7. Amount claimed as bus/No. of Mode of travel. Amount
Train charges Persons
a) Date of outward journey
b) Date of inward journey
I hereby declare that the particulars furnished above are correct. If any of the particulars are found to be incorrect. I realize that I will be liable for suitable action apart from refund of financial assistance, if any received by me.
Signature of the Mine/Beedi worker
Place :
Date :
Certificate by the Management
It is certified that Shri/Smt/Kum. ______is employed in this Mine/Beedi Establishment by me as ______(mention designation) and that his/her wage is ______p.m.
It is certified that no wages have been paid to Shri/Smt/Kum. ______for the period of his/her treatment from ______to ______.
His/her Identity Card/‟B‟Reg. No. is ______
Signature:
Designation:
Name & Address of the
Beedi/Mine management:
Date:
Certificate of the superintendent of the Hospital
Certified that Shri/Smt/Kum. ______who is employed as ______in the Mine/Beedi establishment of M/S ______has undergone treatment for ______in this hospital.
He/She was admitted in the hospital for the said purpose from ______to ______and was discharged on ______-.
He/She needs rest for ______day w.e.f. ______.
Signature of the
Superintendent of Hospital
Name:
Address:
Place:
Scheme no. 5
Annexure-I
FORM „A‟
Application form for financial assistance for Kidney Transplantation or allied treatment
To,
The Welfare Commissioner,
Labour Welfare Organisation,
………………………………
Sir,
I herby apply for financial assistance for undergoing Kidney Transplantation or allied treatment in ………………………………….. (Name of the hospital where the treatment has been recommended by the Medical Officer, Labour Welfare Organisation). In this connection, I submit my particulars as under:-
1. Name of the Applicant in Full
(In Block Letters)
2. Name and address in full of the
Mine/Beedi establishment/Beedi
Contractor/Agent.
3. The date of his/her employment
and total continuous service.
4. Designation or the nature of his/her
employment.
5. His/Her monthly salary/wages (excluding
bonus)
6. (a) Identity Card No. in case of Beedi Workers.
(b) „B‟ Register No. in case of Mine Worker.
Signature of Mine/Beedi worker/Cine worker
Name:
Place:
Date:
CERTIFICATE BY THE MINE MANAGER/OWNER AND IN CASE OF BEEDI WORKER BY OWNER OF ESTABLISHMENT/CONTRACTOR/AGENT
It is certified that Shri/Smt./Kum. ……………………………………. Is employed in this mine/Beedi Establishment by me as ………………………………… continuously with effect from …………………………………….. and information furnished by him/her as above is correct.
Signature:
Designation:
Name and Address of the Mine/Beedi
Management/Contractor.
Date:
Seal of the Mine/Beedi
Establishment
Countersigned by the Owner/Manager of
theBeedi Establishment if the worker is
working under Contractor/Agent.
OWNER/MANAGER
Name:
Designation:
Address:
Date:
CERTIFICATE OF THE MEDICAL OFFICER OF THE LWO
Certified that I have carefully examined Shri/Smt./Kumari ……………………
…………………………….. and found him/her suffering from ………………………..
……………… diseases. In my opinion, his/her admission in the ………………………
……………….. hospital which is recognized by the Govt. of ………………………….
Is absolutely necessary for ………………………………………………………..
His/her Identity Card No. is …………………………………………………
„B‟ Register No. is ……………………………………………………………
Signature:
Name:
Designation:
Name of the Dispensary/Hospital
Dated: ………………
FORM „B‟
Application for grant of subsistence allowance from the Labour Welfare Organisation under the
Scheme for Financial Assistance to Mine and Beedi workers for Kidney Transplantation etc.
To,
The Welfare Commissioner,
Labour Welfare Organisation,
……………………………
Sir,
I herby apply for subsistence allowance and other financial benefits under the scheme for financial assistance to mine and beedi workers for Kidney Transplantation. I have undergone treatment for ……………………………….. in ………………………
……………………………………….. (mention the name of the hospital where the treatment has been taken).
I furnish my particulars as under:-
1. Name of the Applicant in full :
2. Date of birth/Age :
3. Full postal/residential address of the applicant :
4. Full address of the hospital where
the applicant has undergone treatment :
5. The reference No. and date of the
letter from Welfare Commissioner permitting
him/her to undergo treatment in the above
hospital :
6. Source of receipt of Kidney Name and
full address of the Donor :
7. Amount actually incurred by the Applicant
for treatment (Furnish the details with
supporting bills etc. each bill has to be
countersigned by the hospital authorities
with seal and full signature) :
(a) Kidney charges (Donor‟s) : Rs.
(b) Hospital charges including diet etc. : Rs.
(c ) Charges for Dialysis : Rs.
(d) Expenses for pre and post operation : Rs.
Check ups :Rs.
______
Total :Rs.
8. Amount claimed as Mode of travel No. of personsAmount
bus/train charges
(a) Date of outward Journey:
(b) Date of inward Journey:
I hereby declare that the particulars furnished above are correct. If any of the particulars
are found to be incorrect, I realize that I will be liable action for suitable action apart from
refund of financial assistance, if any received by me.
Signature of the Mine/Beedi worker
Place:
Date:
CERTIFICATE BY THE MANAGEMENT
It is certified that Shri/Smt/Kum/ ……………………………… is employed in this
mine/Beedi Establishment by me as …………………………….. ( mention designation)
and that his/her wage is ………………………… p.m.
It is certified that no wage have been paid to Shri/Smt/Kum. …………………….
…………………….. for the period of his/her treatment from ……………………….. to
…………………….
His/her Identity Card/‟B‟ Reg. No. is ………………………………………..
Signature
Designation
Name & address of the
Beedi/Mine management.
Certificate of the Superintendent of the Hospital
Certified that Shri/Smt./Kum. ……………………………………… who is employed as
………………………………………… in mine/Beedi establishment of M/s
…………………………………………………… has undergone Kidney transplantation and
treatment/allied treatment in this hospital.
He/She was admitted in the hospital for the said purpose from …………………
……………… to and was discharged on ………………………………….. He/She needs rest for
…………………………….. daysw.e.f. ……………………………..
Signature of the Superintendent of Hospital
Name
Address
Place:
Scheme no. 6
FORM „A‟
Application form for financial assistance for domiciliary treatment of minor diseases like Hernia, Appendectomy ulcer, Gynaecological diseases and prostate diseases.
To
The Welfare Commissioner,
Labour Welfare Organisation,
………………………………
Sir,
I hereby apply for financial assistance for undergoing domiciliary treatment of minor diseases like Hernia, Appendectomy ulcer, Gynaecological diseases and prostate diseases in
………………………………….. (Name of the hospital) where the treatment has been recommended by the Medical Officer, Labour Welfare Organisation. In this connection, I submit my particulars as under:-
7. Name of the Applicant in Full
( In Block Letters)
8. Name and address in full of the
Mine/Beedi establishment/Beedi
Contractor/Agent.
9. The date of his/her employment
and total continuous service.
10. Designation or the nature of his/her
employment.
11. His/Her monthly salary/wages (excluding bonus)
12. (a) Identity Card No. in case of Beedi Workers.
(b) „B‟ Register No. in case of Mine Worker.
Signature of Mine/Beedi worker/Cine worker
Name:
Place:
Date:
CERTIFICATE BY THE MINE MANAGER/OWNER AND IN CASE OF BEEDI
WORKERBY OWNER OF ESTABLISHMENT/CONTRACTOR/AGENT
It is certified that Shri/Smt./Kum. ……………………………………. Is employed in this
mine/Beedi Establishment by me as ………………………………… continuously with effect
from …………………………………….. and information furnished by him/her as above is
correct.
Signature:
Designation:
Name and Address of the Mine/Beedi
Management/Contractor.
Date:
Seal of the Mine/Beedi
Establishment
Countersigned by the Owner/Manager of the Beedi Establishment if the worker is
working under Contractor/Agent.
OWNER/MANAGER
Name:
Designation:
Address:
Date:
CERTIFICATE OF THE MEDICAL OFFICER OF THE LWO
Certified that I have carefully examined Shri/Smt./Kumari ……………………
…………………………….. and found him/her suffering from ………………………..
……………… diseases. In my opinion, his/her admission in the ………………………
……………….. hospital which is recognized by the Govt. of ………………………….
Is absolutely necessary for ………………………………………………………..
His/her Identity Card No. is …………………………………………………
„B‟ Register No. is ……………………………………………………………
Signature:
Name:
Designation:
Name of the Dispensary/Hospital
Dated: ………………
FORM „B‟
Application for grant of subsistence allowance from the Labour Welfare Organisation under the
Scheme for Financial Assistance to Mine and Beedi workers for domiciliary treatment of minor
diseases like Hernia, Appendectomy ulcer, Gynaecological diseases and prostate diseases.
To,
The Welfare Commissioner,
Labour Welfare Organisation,
……………………………
Sir,
I herby apply financial benefits under the scheme for financial assistance to mine and
beedi workers for …………………………… I have undergone treatment for
………………………… (mention the name of the hospital where the treatment has been
taken).
I furnish my particulars as under:-
8. Name of the Applicant in full :
9. Date of birth/Age :
10. Full postal/residential address of the applicant :
11. Full address of the hospital where
the applicant has undergone treatment :
12. The reference No. and date of the
letter from Welfare Commissioner permitting
him/her to undergo treatment in the above
hospital. :
13. Amount actually incurred by the Applicant
for treatment (Furnish the details with
supporting bills etc. each bill has to be
countersigned by the hospital authorities
with seal and full signature) :
(a) Hospital charges including diet etc. : Rs.
(b) Expenses for pre and post operation
Check ups:Rs.
______
Total :Rs.
I hereby declare that the particulars furnished above are correct. If any of the
particulars are found to be incorrect, I realize that I will be liable action for suitable action
apart from refund of financial assistance, if any received by me.
Signature of the Mine/Beedi worker
Place:
Date:
CERTIFICATE BY THE MANAGEMENT
It is certified that Shri/Smt/Kum/ ……………………………… is employed in this
mine/Beedi Establishment by me as …………………………….. ( mention designation)
and that his/her wage is ………………………… p.m.
It is certified that no wage have been paid to Shri/Smt/Kum. …………………….
…………………….. for the period of his/her treatment from ……………………….. to
…………………….
His/her Identity Card/‟B‟ Reg. No. is ………………………………………..
Signature
Designation
Name & address of the
Beedi/Mine management.
Date
Scheme no. 7
Application Form for seeking financial assistance for marriage of daughter by widow of beedi/mine/cine worker
1. Name of the applicant ______
2. Name of the deceased worker and her/his ______
relationship with the applicant
3. Name of the daughter for whose marriage ______
assistance is sought
4. Name of employer/establishment where the ______
beedi/mine/cine worker was working at the time of his death
5. Date of joining the establishment ______
6. Date of death of the worker ______
7. Details of family members of the deceased beedi/mine/cine worker (enclose copy of Identity
Card as proof)
SI. NoNameRelationship with the workerDate of birth1.
2.
3.
4.
8. Name and address of bridegroom
______
9. Date of marriage (enclose copy of invitation card) ______
Declaration: I solemnly declare that the above particulars are correct the best of my knowledge and belief and in the event of any of the above statements found incorrect. I will return the full amount of financial assistance of the Welfare Commissioner.
Place:
Signature of applicant
Date:
Scheme no. 8
FORM OF APPLICATION FOR GRANT OF SUBSISTENCE ALLOWANCE TO DEPENDANTS OF MINE/BEEDI/CINE WORKERS UNDER THE DOMICILIARY TREATMENT OF T. B. SCHEME.
1. Name in full of the workers
2. Name and address in full of the
mine/beedi establishment where
the worker is employed.
3. Designation or the nature of
his/her employment.
4. The date of his/her employment
and period of service at the Mine /Beedi
Establishment before contacting T.B.
5. His/her monthly salary/wages
(excluding bonus)
6. If he/she (patient) is getting
any financial assistance from
any mine management/beedi
establishment or from any source.
If so, state amount with the period.
7. Number of dependants of the
Mine/Beedi worker (patient)
(Dependants include wife/
husband, unmarried children and
step children residing with and
whollydependant on the worker)
8. Name, age, marital status and
relationship of each dependant.
9. Name and address of the
dispensary/hospital where the
worker is being treated.
10. A certificate that the patient is the
only earning member of the family
and has no other source of income
from Mine Manager/Beedi Establishment
or from District Magistrate or any gazette
officer authorized by himor by the
Headman of village Panchayat.
11. Certificate of the Manager of
Mine/Beedi Establishment/