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NMBS Forms

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Revised Form - C NATINSURE MUTUAL BENEFIT SOCIETY C/o National Insurance Company Limited 3, M iddleton Street, Annexe Building, Kolkata – 700 071 APPLICATION FOR AWARDS TO CHILDREN OF MEMBERS 1. Office Code : Office of Posting Controlling D.O. Controlling R.O. 2. Employee No. Membership No. Date of joining the Society D D M M Y Y Y Y 3. Member’s Full Name : Designation : Department : 4. Particulars of the Child (Awardee as per NMBS Scheme):Name of the Child Age (Years) Examination Passed Na
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  Revised Form -C NATINSURE MUTUAL BENEFIT SOCIETYC/o National Insurance Company Limited 3, Middleton Street, Annexe Building, Kolkata –700 071APPLICATION FOR AWARDS TO CHILDREN OF MEMBERS 1. 2.3.4. Particulars of the Child (Awardee as per NMBS Scheme):- 5. Whether the member applied earlier for Award in same academic year (Put tick Mark in appropriatebox):- 6. Choice of Article:- (As per list of Articles approved by NMBS for the purpose of awarding the child in accordance to his/her entitlement) 1 st Preference Item Code No.2 rd  PreferenceItem Code No.7. Documents enclosed ( Put Tick Mark in appropriate boxes) :-   8.9. NMBS Subscription Deduction Certificate (to be completed by Accounts Dept. of concerned D.O./R.O./H.O. only) Certified that last deduction of NMBS subscription amounting Rs. _______ (Rupees___________________________________) was made from the salary of the member for the month of _____________year_________.This is also certified that there is no interruption in deduction of NMBS subscription from the salary of the member concerned since his/her joining the present office /society. Date :  SIGNATURE OF THE AUTHORISED OFFICER* WITH SEAL *Any Class I Officer of H.O. Accounts Dept./Regional Accountant/Regional Accounts Officer/Divisional Manager/Divisional Accounts Officer Guidelines for the Members:- 1.Award is admissible only on securing 75% and above Marks in SSC/HSC/Graduation Level Final Examination conducted by recognized Boards/Universitiesas per revised scheme.2.If for administrative reasonthe Society isunable to provide the award in kinds then cash award as per the entitlement of the awardee may be sanctioned. 3.Applications received after expiry of three months from the date of publication of result will not be entertained. FOR THE USE OF THE SANCTIONING AUTHORITY  Name of the Article sanctioned Item Code No.Date: _________________  Processed By: Verified By:Sanctioned By:Name of the ChildAge(Years)Examination PassedName of the Board/UniversityYear of passingPercentage of Marks obtainedGrade/ Division/ Class obtained A copy of the related Marks Sheet duly certified by the office of posting and signed by the memberon reverse side of the same. Office Code :Office of PostingControllingD.O.ControllingR.O.Employee No. Membership No. Date of joining the Society   D D M M Y Y Y Y Member’s Full Name :Designation : Department : _______________________ Date: Signature of the Member YESNO  Form -D NATINSURE MUTUAL BENEFIT SOCIETY C/o National Insurance Company Limited 3, Middleton Street, Annexe Building, Kolkata –700 071 APPLICATION FOR SETTLEMNT UNDER SUPPLEMENTARY DEATH RELIEF SCHEME 1. 2.3.4.5. Certificate pertaining torecovery of NMBS Dues as on the date of retirement. (to be completed by Accounts Dept. of concerned D.O./R.O./H.O. only) 1Subscription deducted upto Month___________________Year__________ Amount: Rs.____________________________ 2Uninterrupted recovery of SDRS contribution made upto ( If enrolled under SDRS before 01/04/2009)Circular No.____________________________ Dated _________________________________ 3Uninterrupted recovery of RBS contribution made upto( If enrolled under RBS before 01/04/2009)Circular No.____________________________ Dated _________________________________ Instalment No.____________________ 4Any other dues (Holiday Home Rent etc.)Rs.____________________________________ On account of ___________________________   SIGNATURE OF THE Date: AUTHORISED OFFICER* WITH SEAL   *Any Class I Officer of H.O. Accounts Dept./Regional Accountant/Regional Accounts Officer/Divisional Accounts Officeronly Documents to be attached: a) Attested Photocopy of Death Certificate. b) Attested Photocopy of P.F. Settlement Advice. FOR THE USE OF THE SANCTIONING AUTHORITY Date ofSDRSEnrolment Date of RBSEnrolment AmountSanctioned Adjustmnts :SubscriptionSDRS DuesRBS Dues Other Dues  Net Amount Sanctioned (Rupees__________________________________________________________)Date: _________________  Processed By: Verified By:Sanctioned By: Office Code :Office of PostingControllingD.O.ControllingR.O. Employee No. Membership No. Date of Death   D D M M Y Y Y Y Type of Death: Natural / Accidental  Name of the deceased member: Designation : Department :P.F. Nomination (Strictly as per P.F. Settlement) Sl. No.Name/s of the Nominee/sAgeShare in percentageAddressContact No. 1.2.3.4. The information/particularsfurnished hereinabove are true to the best of my/our knowledge andbelief..I/We would request the appropriate authority to release the payment under SDRS in my/our favour.   __________________________ Date: Signature of the P.F. Nominee/s Rs.Rs.Rs.Rs.Rs.Rs.  Revised Form -G NATINSURE MUTUAL BENEFIT SOCIETYC/o National Insurance Company Limited 3, Middleton Street, Annexe Building, Kolkata –700 071APPLICATION FOR REIMBURSEMENT OF HOSPITALISATION & OPERATION EXPENSES1.  2. 2.3. 4. Particulars of the patient:-5. Particulars of the Disease :-   6.Expenses for the treatment :- 7.Travelling Expenses for outstation treatment (Strike through if not applicable) :- 8. P.T.O. Name of the PatientAge(Years)RelationshipWhether dependent on the Member. (Yes/No) Sum Insured under Employees’ Group Mediclaim Scheme (Rs.) The amount sanctioned by NMBS previously under same head. (Rs.) The year of previous reimbursement from NMBS under same head.Final Diagnosis & Nature of treatment/OperationWhether the diseases / treatment is enlisted under Exgratia Medical Reimbursement Scheme (Yes/No)Date of Admission in the HospitalDate of discharge from the HospitalName & Address of the Hospital/Nursing Home Expenses related to Pre Hospitalisation Period(Rs.)Expenses related to the period of Hospitalisation(Rs.)Expenses related to Post Hospitalisation Period(Rs.)Total Expenditure(Rs.) Amount reimbursed under Employees’ Group Meiclaim Scheme(Rs.)Whether Applied for Exgratia Medical Reimbursement(Yes/No)Sl. No.Journey DateJourneyDistance(K.M.)Mode of JourneyTicket / Money Receipt No.Fare per head (Rs.)No. of HeadsActual Expenditure (Rs.)fromto 1.2.3.4.5.6. T O T A L   Office Code :Office of PostingControllingD.O.ControllingR.O.Employee No. Membership No. Date of joining the Society   D D M M Y Y Y Y Member’s Full Name : Designation :Department : Marital Status: Name of the Spouse: Occupation of the Spouse: Name and address of Employer of the Spouse I solemnly declare that I have never received any amount from NMBS towards Reimbursement of Hospitalisation & Operation Expenses (under Revised Scheme) and/or Travelling Fare for Outstation Treatment for myself or for any of my dependent family member. Information furnished hereinabove are true to the best of my knowledge and belief.  _______________________ Date: Signature of the Member  ( 2 ) 9. Certificate from Accounts/Personnel Dept. of concerned Divisional Office / Regional Office / Head office This is further certified that last deduction of NMBS subscription amounting Rs. ______ (Rupees_________________________  ________________________only) was made from the salary of the member for the month of _____________year_________.This is also certified that there is no interruption in deduction of NMBS subscription from the salary of the member concerned since his/her joining the present office /society.Date : SIGNATURE OF THEAUTHORISED OFFICER* WITH SEAL Amount Claimed under Employees’ Group Mediclaim Policy(Rs.)Amount not payable due to various exclusions as per policy conditions.(Rs.)Sum Insured(Rs.)Amount sanctioned earlier in the current policy year for same patient (Rs.)Amount currently sanctioned forpayment.(Rs.)Balance Amount{(a-b)-e}(Rs.) abcdef  *Any Class I Officer of H.O. Accounts Dept./Regional Accountant/Regional Accounts Officer/Divisional Manager/Divisional Accounts Officer FOR THE USE OF NMBS A)Amount Sanctioned for payment under the Head “REIMBURSEMENT OF HOSPITALISATION & OPERATION EXPENSES” Rs._________________ B)Amount Sanctioned for payment under the Head “REIMBURSEMENT OF TRAVELLING FARE FOR OUTSTATION TREATMENT” Rs.__________________ TOTAL AMOUNT SANCTIONED RS. ___________ (Rupees_____________________________________________only) Processed By: Verified By:Sanctioned By: Guidelines for the Members:-A.REIMBURSEMENT OF HOSPITALISATION & OPERATION EXPENSES 1.The claim should be lodged within 3 months after discharge from the Hospital/Nursing Home or getting payment from Company’s Scheme alongwith attested photo-copies of printed Bill/Money The claim is tenable only for the treatment of a dreadful disease which is enlisted for Exgratia Medical Reimbursement.2.The Patient should be admitted in a Hospital/Nursing Home as an in-patient.3.The claim should be lodged only after full and final settlement of the claim under “Employees’ Group Mediclaim Scheme” for reimbursement of the residual amount from NMBS subject to a maximum of Rs. 10000/-(Rupees ten thousand only) once in a life time of a member. (Expenses related to Pre & Post Hospitalisation period will not be considered). 4.If the member’s spouse is employed, a certificate is required from his/her employer stating whether any amounthas been reimbursed to him/her.5.Claim should be lodged within 3 months after discharge from the Receipts against Bill, Printed Discharge Card, Advices for tests and related cash-memos/Receipts etc. All documents should have full signature of the member in each page. B.REIMBURSEMENT OF TRAVELLING FARE FOR OUTSTATION MADICAL TREATMENT 1.The claim should be related to a claim for Reimbursement of Hospitalisation & Operation expenses. Hospitalisation at outstation is not mandatory for availing travelling farereimbursement but the subject travel should be performed within a  period of one month prior to the hospitalization and two months after the hospitalization for which a claim for reimbursement of hospitalization is lodged with the Society.2.The intimation to the Society is a must prior to commencing the journey for reimbursement of travelling expenses as stated above.3.The claim should be lodged simultaneously with the claim for reimbursement of Hospitalisation an Operation Expenses. Members should use a single claim form (Revised Form “G”) for both the claims together. 4.If the medical expenses are totally covered up under “Employees’ Group Mediclaim Scheme” and there is no residual amount for claiming reimbursement from the Society under heading “Reimbursement of Hospitalisation and Operation Expenses” even then claim for reimbursement of travelling fare may be lodged enclosing all related medical documents along with srcinal/attested photocopy of the railway/air tickets within a period of 3(three) months from the date of discharge from the hospital concerned.5.For claiming of Air Fare the member should enclose separate appeal explaining the extra ordinary situation for which he/she compelled to perform the journey by Air. Considering the merit of the claim and subject to limit of Rs. 4000/-per head for to and fro journey of the patient and one attendant by shortest possible route, the Society may approve Air fare.6.The Society will reimburse the travelling fare for patient and one attendant subject to a maximum of A.C. Two Tier Railway fare for to and from journey from the place of posting to the place of treatment by shortest possible route.7.This reimbursement is available once in a life time for a member.
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