ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

MEDICAL AID APPLICATION FORM

1. Name of the Employee : ...............................................................................................

2. S/o, W/o : ...............................................................................................

3. Residential Address : ............................................................................................................

4. Name of Estt. / Factory : ............................................................................................................with Address ............................................................................................................

5. Designation : ............................................................................................................

6. Token / Staff No. : ............................................................................................................

7. Wages/salary per month : ............................................................................................................

8. Name of the patient : ............................................................................................................9. Relationship with the workers : Self / Spouse / Son / Daughter (un-married).

10. Name of the Disease : ............................................................................................................

11. Brief history of the Disease : ............................................................................................................

12. Name of the hospital with : ............................................................................................................Address ...........................................................................................................

13. Expenditure incurred Rs : ...........................................................................................................14. Whether the applicant availed this benefit earlier : Yes / No

15. Date on which the application is made : .......................................................................................................

Signature of the Employee

N.B. :- 1) Application shall be made within 1 year from the date of treatment / operation. 2) Employee, spouse & childrenare eligible, 3) Those who are in receipt of benefit under ESI or from the management are not eligible.Enclosures : Attested Xerox Copies of 1) Doctor's prescription / Certificate 2) Discharge summary

3) Hospital Bills & Medical Bills

Declaration by the EmployerCertified that the applicant is an employee of our establishment and welfare fund contribution has been paid through

Cheque / D.D./ Challan / Receipt No. : Date :

Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.

Date : Signature of the Employer with seal

OFFICE USE

AffixApplicant

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RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal

v Cancer v Brain tumor v Heart Ailments, v Paralysis treatment v Hysterectomyv Trauma treatment (Serious wounds/injuries caused dut to accidents)

1. Name of the Employee : ...............................................................................................

2. S/o, W/o : ...............................................................................................

3. Residential Address : ...........................................................................................................

............................................................................................................

4. Name of Estt. / Factory with Address : ...........................................................................................................

5. Designation : ...............................................................................................................

6. Token / Staff No. : ...........................................................................................................

7. Wages/salary per month : .............................................................................................................

8. Name & Address of the Labouratory : ..............................................................................................................

9. Name of the doctor & hospital : .............................................................................................................with address

.........................................................................................................

10. Whether the applicant availed this benefit earlier : Yes / No

11. Date on which the application is made: ............................................................................................................

Signature of the workerEnclosures : Attested Xerox Copies of 1) Laboratory Report 2) Doctor / Hospital Report

AffixApplicant

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Declaration by the EmployerCertified that the applicant is an employee of our establishment and welfare fund contribution has been paid through

Cheque / D.D./ Challan / Receipt No. : Date :

Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.

Date : Signature of the Employer with seal

OFFICE USE

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal

ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

MEDICAL AID (AIDS) APPLICATION FORM

1. Name of the applicant : ...............................................................................................

2. Name of the worker (deceased) : .....................................................................

3. Relationship with the employee : ........................................................................................................

4. Residential Address : ........................................................................................................

6. Designation : ........................................................................................................

5. Name of Estt./ Facroty with address : ........................................................................................................

8. Name of the patient : ........................................................................................................

6. Designation : ........................................................................................................

7. Token / Staff No. : ........................................................................................................

8. Wages / Salary per month : ........................................................................................................

9. Date of death : ........................................................................................................

10. Date on which the application made: ........................................................................................................

Signature of the Applicant

N.B. :- The Application for sanction of benefit under the scheme shall be made within 6 months from the date of death.Enclosures : Attested Xerox Copies of 1) Death Certificate 2) Family members Certificate / Ration Card

ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

APPLICATION FORM FOR FUNERAL EXPENSESAffix

ApplicantPhoto

Declaration by the Employer

Certified that the applicant is an employee of our establishment and welfare fund contribution has been paid through

Cheque / D.D./ Challan / Receipt No. : Date :

Date : Signature of the Employer with seal

OFFICE USE

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal

1. Name of the Employee : ...............................................................................................

2. S/o, W/o : ...............................................................................................

3. Residential Address : ...........................................................................................................

6. Designation : ...........................................................................................................

4. Name of Estt./ Facroty with address : .............................................................................................................

8. Name of the patient : .............................................................................................................

5. Designation : ................................................................................................................

6. Token / Staff No. : ..........................................................................................................

7. Wages / Salary per month : ................................................................................................................

8. Date of Accident : ................................................................................................................

9. Nature of Accident : .............................................................................................................

10. Date on which the application made : ................................................................................................................

Signature of the Applicant

N.B. :- 1) The Application for sanction of benefit under the scheme shall be made within 1 year from the date accident 2) Loss of earning capacity should be atleast 40% and above, 3) Employee covered by ESI W.C. Act are not eligible.

Enclosures : Attested Xerox Copies of 1) F.I.R. / Accident Report 2) Medical Certificate about dis-armamentissued by Civil Asst. Surgeon

ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

APPLICATION FORM FOR LOSS OF LIMBS

OFFICE USE

AffixApplicant

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Declaration by the EmployerCertified that the applicant is an employee of our establishment and welfare fund contribution has been paid through

Cheque / D.D./ Challan / Receipt No. : Date :

Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.

Date : Signature of the Employer with seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal

1. Name of the Employee : ...............................................................................................

2. W/o, D/o : ...............................................................................................

3. Residential Address : ................................................................................................................

6. Designation : ..........................................................................................................

4. Name of Estt./ Facroty with address : ............................................................................................................

8. Name of the patient : ..........................................................................................................

5. Designation : ............................................................................................................

6. Token / Staff No. ............................................................................................................

7. Wages / Salary per month : ..............................................................................................................

8. Date of Delivery : ..........................................................................................................

9. Name of the Doctor & Address : .........................................................................................................of the hospital .........................................................................................................

10. Whether the applicant availed the benenit erlier : Yes / No

11. Date on which the application is made : ....................................................................................................

Signature of the ApplicantN.B. :- The Application shall be made within 1 year from the date of delivery2) Benefit under the scheme is limited up to two children, 3) Employees Covered by ESI scheme or any such facilityreceived from the management are not eligible.

Enclosures : Attested Xerox Copies of 1) Doctor's / Hospital Certificate

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ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

APPLICATION FOR SANCTION OF MATERNITY BENEFIT

OFFICE USE

Declaration by the EmployerCertified that the applicant is an employee of our establishment and welfare fund contribution has been paid through

Cheque / D.D./ Challan / Receipt No. : Date :

Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.

Date : Signature of the Employer with seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal

1. Name of the Employee : ...............................................................................................

2. S/o, W/o : ...............................................................................................

3. Residential Address : ................................................................................................................

...........................................................................................................

4. Name of Estt. / Factory with Address : ..........................................................................................................

..........................................................................................................

5. Designation : ..............................................................................................................

6. Token / Staff No. : ............................................................................................................

7. Wages/salary per month : ............................................................................................................

8. Date of operation : ............................................................................................................

9. Name of the doctor&address of : .............................................................................................................the hospital : .............................................................................................................

10. Whether the applicant availed this benefit earlier : Yes / No

11. Date on which the application is made : ........................................................................................................

Signature of the Applicant

N.B. :- 1). Application for sanction of benefit under the scheme shall be made within 1 year from the date of operation 2) The benefit under the scheme up to two children only, 3) those who are dreawing salary / wages more than

Rs. 10,000/- per month and who are in receipt of similar benefit from the management are not are not eligible

Enclosures : Attested Xerox Copies of 1) Doctor's Certificate

ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

APPLICATION FOR SANCTION OF BENEFITUNDER FAMILY PLANNING SCHEME

OFFICE USE

AffixApplicant

Photo

Declaration by the EmployerCertified that the applicant is an employee of our establishment and welfare fund contribution has been paid through

Cheque / D.D./ Challan / Receipt No. : Date :

Certified that the above employee did not benefied under E.S.I. seheme or any such facility provided by the management.

Date : Signature of the Employer with seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal

1. Name of the Employee : ...............................................................................................

2. S/o, W/o : ...............................................................................................

3. Residential Address : ...............................................................................................................

..........................................................................................................

4. Name of Estt. / Factory with Address : ..............................................................................................................

.........................................................................................................

5. Designation : ..............................................................................................................

6. Token / Staff No. : ...............................................................................................................

7. Wages / salary per month : ..........................................................................................................

8. Name of the child (Student) : ............................................................................................................

9. Nature of Disability : ............................................................................................................

10. Class / Course Studying : .........................................................................................................

11. Name & Address of the school / College : ...............................................................................................

12. Date on which the application is made : ...............................................................................................

Signature of the worker

Enclosures : Attested Xerox Copies of 1) Certificate Issued by the Medical Board regarding disability2) Study Certificate

ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

APPLICATION FOR SANCTION OF SCHOLARSHIP(PHYSICALLY HANDICAPPED CHILDREN OF WORKERS)

OFFICE USE

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Declaration by the employerCertified that the applicant is an employee of our establishment and welfare fund contribution has been paid through

Cheque / D.D./ Challan / Receipt No. : Date :

Certified that the applicant is not covered under E.S.I. or any such facility or benefit provided by the management.

Date : Signature of the Employer with seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal

1. Name of the Employee : ...............................................................................................

2. S/o, D/o : ...............................................................................................

3. Residential Address : ........................................................................................................

........................................................................................................

4. Name of Estt. / Factory with Address : .........................................................................................................

.......................................................................................................

5. Designation : .........................................................................................................

6. Token / Staff No. : ...........................................................................................................

7. Wages / salary per month : .........................................................................................................

8. Name of the Student (Self/Son/daughter) : ...................................................................................................

9. Class / Course Studying : ........................................................................................................

10. Name & Address of the school / College : ........................................................................................................

11. Particulars of previous year's study :a) Name of the School / College : ............................................................................................................

b) Class / Course studied : ..........................................................................................................

c) Total Marks obtained & % of marks : ..........................................................................................................

12. Date on which the application is made : ..........................................................................................................

Signature of the worker

Enclosures : Attested Xerox copy of 1) Marks Memo 2) Study Certificate (present class/course)

Declaration by the EmployerCertifed that the applicant is an employee of our establishment and welfare fund contribution has been paid through

Cheque / D.D./ Challan / Receipt No. : Date :

Certified that the applicant is not covered under E.S.I. or any such facility or benefit provided by the management.Date : Signature of the Employer with seal

ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

APPLICATION FOR SANCTION OF SCHOLARSHIP

OFFICE USE

AffixApplicant

Photo

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal

v 10th class Rs. 1000/- v I.T.I Rs. 1000/- v Polythenic Rs. 1500/- v Medicine Rs. 2000/-v Engineering Rs. 2000/- v Law Rs. 2000/- v BSC (AG), BSC (Vet) , BSC Nursing,BSC Horticulture Rs. 2000/- v D.M.L.T Rs. 2,000/- v M.L.T. Rs. 2,000/- v B.A.M.S. Rs. 2,000/-v B.D.S Rs. 2,000/- v D.H.M.S Rs.2,000/-

ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

MARRIAGE GIFT APPLICATION FORM

1. Name of the Employee : ...............................................................................................

2. S/o, W/o : ...............................................................................................

3. Residential Address : .................................................................................................................

4. Name of Estt. / Factory : ...............................................................................................................

with Address ...............................................................................................................

5. Designation : ...................................................................................................................

6. Token / Staff No. : ...............................................................................................................

7. Wages/salary per month : ....................................................................................................................

8. Name of the Bride (Daughter/ self) : .................................................................................................................

9. Date of Birth : ............................................................................... Age ............................

10. Place of marriage : ....................................................................................................................

11. Date of Marriage : .....................................................................................................................12. Whether the applicant availed : Yes / No

this benefit earlier13. Date on which the application is made : .......................................................................................................

Signature of the workerN.B. :- 1) The Application shall be made within 6 months before or after from the date of marriage

2) The benefit is applicable for one daughter only. 3) Salary / wages of the worker should not exceed Rs. 10000/ p.m.

Enclosures : Attested Xerox Copies of 1) Wedding Invitation 2) Marriage Photo3) Age proof certificate 4) Marriage Certificate

OFFICE USE

AffixApplicant

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Declaration by the employerCertified that the applicant is an employee of our establishment and welfare fund contribution has been paid through

Cheque / D.D./ Challan / Receipt No. : Date :

Certified that the monthly salary / wages of the above wokrer is Rs. (Rupees...........................................

..................................................................................)

Date : Signature of the Employer with seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal

1. Name of the applicant : ...............................................................................................

2. Name of the employee (Deceased) : ......................................................................

3. Relation ship with the Employee . .........................................................................................................

4. Residential Address : ...........................................................................................................

........................................................................................................

5. Name of Estt / Factory with address : ..........................................................................................................

6. Designation of the deceased employee : .......................................................................................................

7. Token / Staff No. : ............................................................................................................

8. Wages/salary per month : ............................................................................................................

9. Date of the Accident : ............................................................................................................

10. Date of death : ...........................................................................................................

11. Nature of Accident : ...........................................................................................................

12. Date on which the application is made : ...........................................................................................................

Signature of the Applicant

N.B. :- Application for sanction of amount under the scheme shall be made within 1 year from the date of deathEnclosures : Attested Xerox Copies of 1) Death Certificate 2) F.I.R. 3) Postmortem Report

4) Family Member Certificate or Ration Card.

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ANDHRA PRADESH LABOUR WELFARE BOARDHYDERABAD

EMERGENT ECONOMIC AMELIORATIVE RELIEF (EEAR)APPLICATION FORM

Declaration by the employer

Certified that the deceased employee worked in our establishment and welfare fund contribution has been paid throuth

Cheque / D.D./ Challan / Receipt No. : Date :

Certified that the applicant is not covered under E.S.I. or any such facility or benefit provided by the management.

Date : Signature of the Employer with seal

OFFICE USE

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management. Recommended forsanction of the benefit.

Date : Signature of ALO &Office Seal

RC No............................. Date :........................

It is certified that the above particulars are correct andthe applicant did not avail the similar benefit from anyGovernment department or Management.

Date : Signature of ACL &Office Seal