Emergency Certificate for Medical Claim

EMERGENCY CIRTIFICATE

This is to certify that Smt. ________________________ w/o Sh. __________ admitted this hospital on ______________ . She was suffering from_______ .

It is further certified that when she brought to this hospital she was in very serious condition.

CGEIS Form

FORM NO.13

[See Para 6]

Central Government Employee’s Group Insurance Scheme 1984

Date of Joining Govt. Service	Date of Admission to the CGEI Scheme	Group to Which admitted	Rate of monthly contribution (Rs.)	Period		Events with exact date affecting Cols.(3) and (4)	Remarks
				From	To
(1)	(2)	(3)	(4)	(5)		(6)	(7)

Undertaking by the retited Employee

Undertaking to Refund Excess Payment

I herein undertake to refund all excess payment, if any, paid to me through claim of my Leave Encashment.

Dated:                                                         Name of Official with Designation

Sanction EL for Retired/LTC Leave Encashment

Office Order No _______________________

                                                                        Dated:  _______________________________

Sanction

I, Head of Office of the ________________________________________________ , N. Delhi hereby accord a sanction under Rule 39(2)(b) of CCS (leave) Rules 1972 of cash payment in lieu of unutilized balance of Earned Leave for ________ days(_____________ ) at the credit of Sh./Smt. _________________________________________ who has retired on _______________. The detail of amount is as under:-

Last Basic Pay                                                :

DA as on Date                                                :

No. of Days                                        :

Amount of leave Encashment             :

Head of Office

No.                                                      Dated:

1.      DDO Concerned with the direction to draw the amount.

2.      The PAO concerned through the DDO.

3.      The official concerned.

Head of Office

                                                           

DCRG Retirement Claim Proforma

Form T.R. 37-A

(See Note below Rule 366)

Bill for withdrawing Death-cum-Retirement Gratuity

Head of A/c “2071 Pension”             District                        :

            & other retirement                Voucher No.              :

            Benefits gratuities                  List of payments for  :  As per authority attached

Name of Gratuitant     : ________________________________________No. & date of letter of authority of the pay& Account office _______________ dt. _______________ P. P. O. No.:  ______________________________.

                                                                                                            Amount (Rs.)

Death-cum-Retirement Gratuity (Gross)                                            _________________

Less deduction

Withheld amount                                                                                _________________

Recovery towards Account                                                                _________________

Total deduction                                                                                   _________________

Net amount payable                                                                            _________________

Net amount required for payment (in words) _______________________________________

Pay Rs. ______________                                           Signature: ________________________

(Rs. _____________________________                   Designation_______________________

________________________________                    Station ___________________________

                                                                                    Dated: ___________________________

Treasury Officer                                                          Contents received Pay to Shri/Smt.

Examined & entered                                                   _________________________________

Treasury Accountant                                                   Signature of DDO

For use in pay & accounts office.

Admitted for Rs. ________________

Objected to Rs. _________________

Nature of Objection______________

Auditor                                   Superintendent                                                Gazetted officer

CGEIS Proforma For Retired Person

ANNEXURE-C

Bill No.                                   Receipted Bill                         Head of Account

                                                                                    Major Head ‘8011’ INSURANCE

                                                                                    Pension Fund U. T. Govt.,

                                                                                    Employees Group Insurance Scheme,

                                                                                    Insurance Panel Saving Panel._________

Received sum of Rs. ___________ (Rs. ______________________________________ ). The total of entitlement of Rs. ___________ from the Insurance Fund and/ or Rs. _________

Name: ________________________________________ Designation: _________________ * Group A – B – C – D under the Central Govt. Employees Group Scheme 1980.

Dated:                                                                         Signature (Sig. of receiptent(s)

                                                                                    Name in Block Letter)

FOR USE IN DEPARTMENTAL OFFICE

a)      Relevant Bio-Data of the Member.

1.      Type of Group of the member (i.e. lowest group) viz. D/C/B/A on initially joining the Scheme on ______________.

2.      Year of acquiring membership of higher group    i) C      19________.

ii) B     19________.

iii) A    19________.

b)      Countersigned for payment of Rs. __________ (Rs. _________________________ ) to claimant(s) crossed/Demand Draft to be issued in favour of Claimant(s) Sh./Smt. ___________________________________________________________________ .

Signature _______________________

Date:                                                                           Designation _____________________

FOR USE IN ACCOUNTS OFFICE

Passed for payment for Rs. _______________ (Rs. ________________________________) through cheque(s).

                                                                                                ACCOUNTS OFFICER