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Claim Submission Form
1(a) Name Of the claimant worker
*
1(b) Gender
Male
Female
One option is required.
(2) Father's Name of the claimant worker
*
(3) Address (Postal)
*
(a) During period of employment
*
(b) Present and permanent address
*
(4) Date of birth of the claimant worker
*
5(a)Email address of the claimant worker,if any
5(b)Aadhar Number
*
5(c)Mobile number of the claimant worker
*
5(d) whatsapp number of the claimant worker,if any
(6) Valid photo I.D. of the claimant worker (file size should not greater then 4 Mb)
*
Aadhar card
Driving Licence
Bank passbook with photo
7 Worked on which post (Class III/ Class IV), Mention
Class III
Class IV
(a) Zone
(b) Division
(c) Branch
(8) Period of work
*
(a) From Date
To Date
(b) From Date
To Date
(c) From Date
To Date
*
(9) Document submitted by claimant worker to prove - Appointment and working(file size should not greater then 50 Mb)
(For multiple selection first press Ctrl and then select)
(10) Appointment letter date
(a) Appointment Authority's name and designation
(11) Whether claimant worker had submitted any claim previously? if yes, photocopy of it be submitted(file size should not greater then 4 Mb)
Yes
No
One option is required.
(12) Whether claimant's service was terminated
Yes
No
One option is required.
(13) Whether any departmental enquiry or criminal case was initiated against the claimant? If yes, Its results
Yes
No
(14) Whether claimant worker desires a personal hearing, If yes
Zonal HQ
--Select Zone--
Central Zone / Bhopal
Eastern Zone / Kolkata
East Central Zone / Patna
Northern Zone / Delhi
North Central Zone / Kanpur
Southern Zone / Chennai
South Central Zone / Hyderabad
Western Zone / Mumbai
Virtual Hearing
(15) whether claimant has original documents in support of his claim and above stated facts. Tick whichever is applicable
Yes
No
One option is required.
(16) Remarks,if any
(17) Declaration
I do hereby declare that the above stated information is true and correct to the best of my knowledge and belief.
Note: If any document is submitted in Regional Language, then English translation of the document should be annexed
Submit
