Where the Central Government is satisfied that the operation of any of the provisions of this scheme causes undue hardship to the claimants, it may, by order, for reasons to be recorded in writing, relax the requirement of that provision in a manner not inconsistent with the provisions of the Act or the rules made thereunder.
[F.No. 18-3/9 -HSMD] Dr. G. K. Pandey Adviser FORM-I (Under section 7A of the Public Liability Insurance Act, 1992 ) I / we-------------------------------------------------- -as legal representative(s) of the deceased/injured----------------------------- hereby give undertaking that I / we shall refund the amount of relief awarded to me/us under this Act by the Claims Settlement officer to the owner in case I / we am/are awarded any other compensation or amount in lieu of or by way of satisfaction of –a claims for compensation in respect of death or grievous hurt to-- --------------------------------------------------------------------------------------------under other provisions.
Signature of the legal representatives of the deceased/injured person.
6 F 0 R M - II SERIAL NO:
Collector:
Date :
O R D E R I hereby sanction Rs.----------------------- (Rupees.--------------- -------------------------------- as an interim relief in respect of thedeath/injury Of Shri/Shrimati/Km. ______________________________resulting from chemical accident which took place at------------ (Name of the unit & Place) on ----------------------------------- to Shri/Shrimati/Kumari -------------------------as the legal representative of the deceased or to ---------------------------------------(Name of the injured).
Signature of the Collector Copy to:
1. Fund Manager
2. Office of the Insurance Company
3. The Claimant
4. Collector office file
5. The Owner concerned 7 F 0 R M - III ERF Scheme under the Public Liability Insurance Act 1991
1. Control No. (To be Allotted by Fund Manager)
2. Name of Insured Owner
3. Business
4. Address
5. Territorial Limits
6. Name & Quantities of hazardous substances handled by owner
7. Address of Collector under which Territorial limit is the unit handling hazardous substance falls.
8. Annual turn-over
9. Paid up capital as defined Sec.4 (2A) of the Act (as on the date of the policy).
10. Policy Period
11. Indemnity Limit
12. Premium
13. Contribution to the Environment Relief Fund
14. Date of proposal and declaration.
15 Address of Policy Issuing: office to whom payment has been made
16. Date and particulars of payment to insurer Date:
Place: For .........{ owner } Name & Designation Authorised Signatory NOTE: One copy each of the duly signed form is to be sent directly to the General Insurance Company, the District Collector or District Magistrate and Ministry of Environment and Forests by the owner and two copies are to be submitted to the 'Insurer. The insurer will send one copy to the Fund Manager duly signed along with contribution towards ERF.
8 F 0 R M - IV Sanction Order NO.
Dated :
DISCHARGE RECEIPT Received with thanks from--------------------------------------------------- Insurance Co. Ltd. a sum of Rs.-------------------------------------------being the interim relief under the Public Liability Insurance Act,1991 in part/full settlement of the claim for accident occurred to me/to the, deceased person-------------------------- - --------------------------------(Name of the deceased) on ------------------------------- (date of accident) at---------------------------------(Name of the Place). The amount has disbursed to me vide cheque / challan No.--------------------------------- Dated------- ----- --- drawn on-----------------------------------------from (Name of Collector's Office).
Signature on revenue Stamp by beneficiary/victim ******