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FORMS for GIS - LOCAL BODIES
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01 |
Form
I |
Number
of Employees in office as on Ist January |
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02 |
Form
II |
Statement
of new employees admitted to the scheme. |
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03 |
Form
III |
Statement
of Retirement and other withdrawals |
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04 |
Form
III ( A ) |
Group
Insurance Scheme data sheet |
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05 |
Form
IV ( I ) |
Statement
showing the death details of employees |
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06 |
Form
IV ( II ) |
Statement
showing the death details of employees |
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07 |
Form
IV ( III ) |
Statement
showing the death details of employees |
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08 |
Form
V |
Statement
showing the staff strength of every month details |
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09 |
Form
VI |
Statement
showing the remittance details of every month |
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10 |
Form
VII |
Nomination
form of GIS |
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11 |
Form
VIII |
GIS
– Payment Sanction Proceedings format |
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12 |
Form
IX |
Register
of Sanction and Payment |
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13 |
Form
X |
Questionnaire
to be adopted by Inspecting Officers |
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14 |
Form
XI |
Cheque
slip for claim reporting unit. |
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15 |
Form
XII |
Cheque
slip for Sanctioning Authority for Claims. |
FORM
I
GROUP
INSURANCE SCHEME FOR THE EMPLOYEES OF CHENNAI AND OTHER
CORPORATIONS, MUNICIPAL EMPLOYEES , EMPLOYEES OF PANCHAYAT
UNIONS , TOWN PANCHAYATS ( PRESENTLY SPECIAL VILLAGE PANCHAYATS
) AND PANCHAYAT TOWNSHIP COMMITTEES.
CALENDER
YEAR OF BIRTH NO: OF EMPLOYEES
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TOTAL
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We
certify the correctness of the above statement of the number of
employees covered under the scheme as on …………………..………………….
Effective Date / Annual Renewal Date.
For
State Government of Tamil Nadu
Date:
Place:
FORM
II
GROUP
INSURANCE SCHEME FOR THE EMPLOYEES OF CHENNAI AND OTHER
CORPORATIONS, MUNICIPAL EMPLOYEES , EMPLOYEES OF PANCHAYAT
UNIONS , TOWN PANCHAYATS ( PRESENTLY SPECIAL VILLAGE PANCHAYATS
) AND PANCHAYAT TOWNSHIP COMMITTEES.
STATEMENT
OF NEW EMPLOYEES ADMITTED TO THE SCHEME
During
…………………………Date ……………………Month
of ………………………..
No.
of New Entrants:
Total
Premium: Average rate of premium
=
No. of new entrants X t / 12
Rs.
We
certify that the number of new entrants to the Scheme during
………………. date…………Month of
…………………200 ( year ) and the total amount of
premium payable in respect of them is as above.
For
State Government of Tamil Nadu
Date:
Place:
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Note:
" t " is the number of months from date of admission
to the next Annual Renewal Date rounded off to the next higher
month.
FORM
III
GROUP
INSURANCE SCHEME FOR THE EMPLOYEES OF CHENNAI AND OTHER
CORPORATIONS, MUNICIPAL EMPLOYEES , EMPLOYEES OF PANCHAYAT
UNIONS , TOWN PANCHAYATS ( PRESENTLY SPECIAL VILLAGE PANCHAYATS
) AND PANCHAYAT TOWNSHIP COMMITTEES.
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STATEMENT
OF RETIREMENTS AND OTHER WITHDRAWALS
(
EXCLUDING DEATHS ) FOR 200 ( year )
(
MONTH )
We
certify the number of employees who have gone out of the scheme
during
………………….....200
( year ) by way of retirements, leaving service terminations
etc. ( excluding deaths while in service ) is
…………………………………
For
State Government of Tamil Nadu
Date:
Place:
FORM
III ( A )
GROUP
INSURANCE SCHEME – DATA SHEET
Name
of Office:
Name
of the Place:
District:
Number
of lines in the whole list
(
This will be same as the last serial number in the list )
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Sl.No: |
Name |
Year
of Birth |
If
left the Office during the year , write the date of
leaving |
If
joined the Office during the Year, write the date of
joining. |
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FORM
IV ( Part I )
GROUP
INSURANCE SCHEME FOR THE EMPLOYEES OF CHENNAI AND OTHER
CORPORATIONS, MUNICIPAL EMPLOYEES , EMPLOYEES OF PANCHAYAT
UNIONS , TOWN PANCHAYATS ( PRESENTLY SPECIAL VILLAGE PANCHAYATS
) AND PANCHAYAT TOWNSHIP COMMITTEES.
PART
I :
1.
Name of the employee --
2.
Sex --
3.
Roll No. / ticket No. identification
No.
( wherever applicable ) --
4.
Designation and Department --
5.
Name & Address of the Office to
which
attached --
6.
Date of birth as per Service Record --
7.
Date of Death --
8.
Cause of Death --
9.
Proof of death obtained --
10.
Remarks if any --
(
i ) Certified that the above particulars are true and correct.
(
ii ) (a) Certified that monthly recovery of Rupees…………………………………….
(
as per time to time changes ) towards Group Insurance
Scheme has been duly effected from his / her salaries
for the entire period of service till death.
(
OR )
(b)
Arrears of deduction of Rupees
……………………………………………….
shall
be adjusted from the lump sum payable to the beneficiary.
Date:
Place:
Seal
(
Sd. )
Claim
Reporting Unit Officer
Name
in Block Letters
Designation
Address
FORM
IV ( Part II )
(
Paragraph 7- 2 )
PART
II :
To
be filled in by Designated Authority for Claim. ( DAC ) who is
also the Sanctioning Authority.
Serial
No. allotted for claim.
WE
CERTIFY THAT
1)
The above mentioned employee has been member of the
Group Insurance Scheme as eligible employee on date of
death
2)
( a ) Monthly recovery of Rupees
……………………………………………………..
has
been duly effected from his / her salaries
(
b ) Arrears of deduction of Rupees
………………………………………………….
shall
be adjusted from the lump sum payable to the beneficiary.
3)
We have obtained proof of death as per the Rules of the Scheme
and
satisfied
ourselves about the death of the employee.
We
declare that the above particulars and statements are true to
the best of our knowledge and belief.
Date:
Place:
Seal
(
Sd. )
Designated
Claim Authority
Name
in Block Letters
Designation
Address
FORM
IV Part III )
PART
III :
ADVANCE
DISCHARGE RECEIPT TO BE SIGNED BY
DESIGNATED
AUTHORITY FOR CLAIM
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We
do hereby acknowledge receipt from the LIFE INSURANCE
CORPORATION OF INDIA a sum of Rupees. ( Rupees
Only
) in full satisfaction and discharge of all our claims and
demands arising in terms of the Master Policy relating to the
above Group Insurance Scheme towards Death claim arising out of
death of aforesaid eligible employee covered under Group
Insurance Scheme.
Dated
at this day of 2006
Rev.Stamp
Signed
by the above ( Signature in full )
Mentioned
party /
Parties
in presence of of designated authority for claim
Name:
………………………..
Designation:
Signature:
Address:
Name
of witness :
Designation:
Address
:
FORM
V
REGISTER
OF STAFF STRENGTH
NAME
OF THE LOCAL BODY
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Sl.No
1 |
Month
2 |
No.
of persons in acquaintance roll of previous month
3 |
Add
new entrance
4 |
Deduct
transfers and retrenchment
5 |
Net
no. on roll eligible for the scheme
6 |
Death
cases
7 |
No.
carried to next month
8 |
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Signature
of
Sanctioning
authority
FORM
VI
NAME
OF THE LOCAL BODY
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Sl.No
1 |
Month
2 |
Total
no. of employees
3 |
Total
amount deduct from employees
Rs.
4 |
Total
amount remitted
5 |
Chalan
No. and Date |
Remarks
7 |
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(a)
Current |
(b)
Arrear |
(c)
Total |
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Signature
of
Sanctioning
authority
FORM
VII
NOMINATION
FOR GROUP INSURANCE SCHEME
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Name
and Address of Nominee
* |
Relationship
With
the employee |
Age
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Dated
this day of
Signature
of the employee
Witness
to Signature:
1.
2.
CERTIFIED
that the above nomination is in order with reference to the
rules mentioned in paragraph 5 – 1 of the Hand Book of
Instructions.
Signature
of the Countersigning
Officer.
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*
In the case of nomination of minor, name and address of the
person to whom the cheque should be handed over, should be
specified just below the name of the nominee within brackets.
FORM
VIII
Proceedings
of…………………………………………………………………………
Present…………………………………………….
Sub:
GROUP INSURANCE SCHEME – Payment of Lump sum
benefit
- Ordered.
Ref:
Proposals of the………………………………………
Dated:…………..
ORDER:
The
Claim Reporting Unit Officer……………………………………………..has
stated in his reference cited, that Thiru / Tmt……………………………………..who
was working as……………………………………passed
away on………………………………………
The
cause of death is reported to be………………………………………………
Thiru
/ Tmt…………………………………was admitted to the
GROUP INSURANCE SCHEME with effect from…………………………………….and
has been contributed to the scheme till his death.
The
deceased has nominated Thiru / Tmt………………………………………………
( Relationship ) to receive the lump sum under the GROUP
INSURANCE SCHEME .
Sanction
is therefore accorded for the payment of Rs………………………...
to Thiru / Tmt……………………………………….……………..(
Relationship ) or ( legal heir) of Thiru / Tmt…………………………
……………………(
Designation and Office ) who expired on……………………..while
in service.
The
amount is payable by the Life Insurance Corporation of India,
Madras Division.
(
SIGNATURE )
To
The
Beneficiary,………………..
Copy
to The Executive Officer. ( He should send a report indicating
the date of receipt of cheque and the date of disbursement to
the beneficiary.
Copy
to The Assistant Examiner of Local Fund Accounts.
Copy
to The Collector, ………………………….District.
Copy
to The Director of Treasuries and Accounts, Chennai – 15.
Copy
to The Director of Rural Development, Chennai – 15.
Copy
to The Inspector of Municipalities, Chennai - .
FORM
IX
NAME
OF THE LOCAL BODY
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S.
No. |
Designation
of Name
and
Employees
on whose
behalf
payment
is
sanctioned |
Date
of
Birth
(of
the
Deceased Employee |
Date
of
Death
(of
the
Deceased Employee) |
Cause
of Death |
Date
of
Dispatch
of claim
and to
whom sent |
No.
and
Date of
sanction
order with
the name
of the
sanctioning authority |
To
whom
sanctioned (Relationship
to the
d
eceased employee) |
Date
of
receipt of
cheque
from LIC
and date of dispatch
to
the claim reporting unit |
Date
of
Deposit of
cheque
into
the
bank or
Treasury |
Date
of
disbursement
of
the
Cheque
to
the beneficiary |
Remarks |
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FORM
X
QUESTIONAIRE
TO BE ADOPTED IN RESPECT OF INSPECTION OF THE ACCOUNTS AND OTHER
RECORDS RELATING TO GROUP INSURANCE SCHEME
1.Admittance:
(
i ) What is the sanctioned strength of the Office?
(
ii ) What is the actual strength at the time of inspection?
(
iii ) Have all the eligible persons, including those on
deputation been admitted to
the
scheme.
(
iv ) Whether the amounts, deducted and remitted into the
treasury tally with the
eligible
number.
2.
Nomination:
(
i )Have in nomination been obtained from all the employees
admitted to the
scheme.
(
ii) Have all the nominations been countersigned by the competent
authority and
pasted
in the service register/ Service Roll of the individual with
necessary
entries
in the service register.
3.
Maintenance of Accounts:
(
i ) Are the register of recoveries in form VI maintained?
(
ii ) Are the amounts recovered have been remitted to Govt.
account with in 15
days
from the date of Deduction.
(
iii ) Whether register sanctioned and payment maintained.
4.
Sanction file:
(
i )Has the death certificate been obtained from proper authority
and filed in the
sanction
file?
(
ii ) Has the lump sum payment of Rs.1,50,000 been sanctioned to
the nominee of
the
deceased Service?
(
iii ) Has the lump sum payment to the nominee or the legal heir
of the deceased
servant
as the case maybe been made under proper acquaintance and under
personal
supervision of the head of Office and witnessed by another
employee.
(
iv ) In case of dispute among the claimants, whether the amount
has been
deposited
in the bank and if so whether necessary call book entry has
been
made
to watch further action.
(
v ) If the payment has been ordered to be paid to the minor
child of the deceased
the
name of the bank in which the deposit has been made.
FORM
XI
CHECK
SLIP FOR THE FILE IN THE OFFICE OF CLAIM REPORTING UNIT
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1. |
Name
and Designation of the
deceased
employee
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2. |
Date
of death
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3. |
Date
of application from the nominee , if any
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4. |
Name
of Nominee and his relationship
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5. |
Death
Certificate or proof for death
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6.
(
i ) |
Claim
report
Number
and date of sanction order from sanctioning authority for
claim
(
whether sanction of Government has been obtained in
respect of suicide and murder cases )
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7. |
Date
of receipt of cheque from sanctioning authority ( Cheque
No: and Date)
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FORM
XI
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8. |
Date
of Deposit into Treasury Bank
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9. |
Date
of disbursement to beneficiary
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10. |
Acquittance
with the signature of the witness
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11. |
Date
of deposit into Bank in case of disputed case or minor
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12. |
Date
of dispatch of final report to Sanctioning authority for
claim
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Signature
of
Sanctioning
authority
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FORM
XII
CHECK
SLIP FOR THE FILE IN THE OFFICE OF SANCTIONING AUTHORITY FOR
CLAIM
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1. |
Date
of receipt of claim from reporting unit
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2. |
Date
of issue of sanction order
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3. |
Date
of dispatch of claim to LIFE INSURANCE CORPORATION
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4. |
Date
of receipt of cheque from LIFE INSURANCE CORPORATION
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5. |
Date
of dispatch of the cheque to Claim Reporting Unit.
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6. |
Date
of receipt of disbursement report.
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7. |
Date
of next action call book entry in the case of disputes and
minors respectively.
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Signature
of
Sanctioning
authority
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