Where an insured person is convicted under section 84 of the Act, he shall not be entitled to any cash benefit admissible under the Act for a period of three months for first conviction and six months for each subsequent conviction from the date of receipt of judgement of the court in the concerned office of the Corporation.
FORMS FORM 1 (See Rule 21) Book Receipt Number Number Received from ...............................................the sum of Rs. ....................................... (in words) on account of ................................................................ .
Rs. .................. .
Chief Accounts Officer Authorised Officer Entered in Cash Book page Number .......
Accountant Book Receipt Number Number Received from ......................................... the sum of Rs. ......................................... (in words) on account of .............................................................. .
Rs. .................. .
Chief Accounts Officer Authorised Officer The Employees’ State Insurance Corporation.
—— FORM 2 [See Rule 20-A (2)] Application to Medical Appeal Tribunal Insurance No : ..................................
I, ................................................... (full name of appellant) .............................. of …………....…..................…........ (Address of appellant) appeal against the decision on …............. (date) of the Medical Board at ................................... (Address) notified to me by letter (from ..................………. ) dated …….....…….. that : — *(1) there is no appreciable disablement ;
*(2) this disablement should continue to be treated as temporary and the next date when the case should be referred to the Medical Board is ............................................................ ; or *(3) the disablement can be declared to be of a permanent nature and —
(i) the extent of loss of earning capacity can be assessed provisionally or finally ;
(ii) the assessment of the proportion of loss of earning capacity whether provisional or final ; and
(iii) in case of a provisional assessment, the period for which such assessment shall hold good.
The following are the grounds of my appeal : — List of documents, if any.
Date Signature of appellant.
The statement of facts contained in this application is, to the best of my knowledge and belief, true and correct.
To Signature of the appellant.
Chairman of Medical Appeal Tribunal.]
—— * Delete whichever does not apply.