
 State of Bihar - Act
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 Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme 2011
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 BIHAR
   
 India
 
 Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme 2011
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 Rule BIHAR-SHATABDI-UNORGANIZED-SECTOR-WORKERS-AND-ARTISANS-SOCIAL-SECURITY-SCHEME-2011 of 2011
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* Published on 30 March 2012
* Commenced on 30 March 2012
 Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme 2011
 
 Published vide Notification No. S.O. 88, dated 30th March 2012
 
 Last Updated 4th February, 2020
 
 [Dated, 19th March 2012]
 
 S.O. 88, dated 30th March 2012. - Whereas the State Government is satisfied that it is necessary to provide safety net to the States unorganized sector workers and artisans, working in the State, in the event of their death, disabilities and injuries arising on account of accidents, to provide assistance in cases of serious ailments, to provide scholarship to their children for pursuing school, vocational and technical education and to frame the "Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme 2011" to achieve the said objectives.
 
 Now, therefore, in public interest and in order to achieve the objectives as contained in Article 39(e)  of the Constitution of India, the Governor of Bihar hereby makes the following Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme 2011:-
 
### 1. Short title, extent & commencement.
(1) This scheme may be called the Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme 2011.
 
(2) It will extend to the whole of the State of Bihar.
 
(3) It will come into force from 1st April, 2011.
 
### 2. Definitions.
(1) In this scheme, unless the context otherwise requires -
 
(a) "Accident" means accident caused by external violence which is apparent in nature and shall include
 
 Train or road accident, electric shock, snake-bite, drowning, fire burn, falling from tree or building, attack by wild animals, terrorist or criminal attack etc. However, this list is illustrative and not exhaustive:
 
 Provided that, it shall not include self inflicted injury or suicide or accident caused under inebriated condition or death or disability suffered while committing criminal offences;
 
(b) "Accidental death" means death caused by an accident:
 
 Provided that, death occurring within 180 days of the happening of the bodily injury resulting solely and directly from the accident and independently of any other cause shall be covered under this scheme;
 
(c) "Artisan" means a self employed domicile of the State who works in the State and earns his livelihood from avocations like black smithy(Lohargiri), basket making, bullock/ cycle/ hand cart pulling, carpentry(Badhaigiri), cattle rearing, cattle grazing, cloth dyeing (Rangrezgiri), cycle rickshaw pulling, doll making, earthen pot making (kumhargiri), embroidery, fishing and boat driving (Mallahgiri), hair dressing, handicraft, idol making, madari show, auto rickshaw driving, rope making, shoe making/repairing, sheep/goat rearing, sewing, stitching (Rafoogar), stone cutting, street hawking, street vendors, utensil making (Thathera), vegetable and fruit vendors, weaving and any other avocation of like nature. However, this list is illustrative and not exhaustive;
 
(d) "Block Development Officer" means Development Officer of the Blocks appointed by the State Government;
 
(e) "Circle Officer" means Circle Officer of the Circles (Anchals) appointed by the State Government;
 
(f) "Dependent" means widow of the deceased and husband in case of female persons, dependent son, unmarried daughter and parents; in case of deceased unmarried persons, father and mother jointly;
 
 Note. - The grant on account of death shall be distributed among all dependents in equal proportion.
 
(g) "District Magistrate" means District Magistrate and Collector of the district appointed by the State Government. This will also include the Additional Collector and/or Additional District Magistrate and senior Deputy Collector posted in the district and specially empowered by the District Magistrate to carry out all or any function assigned to him under this scheme;
 
(h) "Incurable disease" means any of the diseases mentioned in the schedule I of this scheme;
 
(i) "Labour Superintendent" means Labour Superintendent in charge of a district appointed by the State Government;
 
(j) "Natural Death" means death caused by natural causes and not by any accident;
 
(k) "Permanent Partial Disability" means loss of one eye or one limb due to an accident and includes cases of paralysis of one limb caused due to accident or otherwise;
 
(l) "Permanent Total Disability" means loss of two eyes or two limbs or loss of one eye and one limb due to an accident and includes cases of paralysis of two limbs or brain caused due to accident or otherwise;
 
(m) "Scheme" means Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme 2011;
 
(n) "Society" means the Bihar State Labour Welfare Society established by the State Government by this name and its successor;
 
(o) "State Government" means the Government of Bihar;
 
(p) "Unorganized Sector" means the employments included in the list of scheduled employments under the Minimum Wages Act, 1948;
 
(q) "Worker" means a domicile of the State of Bihar working for wages in the unorganized sector in the State;
 
(2) Words and expressions used herein but not defined shall have the same meaning as widely understood in the State of Bihar.
 
### 3. This scheme shall also apply in cases of death caused by atomic radiation and war.
 
### 4. This scheme shall apply to all workers and artisans falling in the age group of 18 to 65 years as on the 1st July of the calendar year in which the accident occurred.
 
 Provided that, this scheme shall not apply to the persons who are covered under centrally sponsored Aam Aadmi Bima Yojana (AABY) .
 
 Provided further that, the scheme shall not apply to the construction workers registered under the Building and other Construction Workers (Conditions of Service) Act, 1996 and Rules made there under.
 
### 5. Circle Officer shall decide legal dependent (s)  in the above order of the descendants. If there is any dispute against the dependent (s) as decided by the Circle Officer, an appeal shall lie before the District Magistrate whose decision shall be final.
 
### 6. Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme.
 - The name of the scheme shall be the Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme and following benefits shall be payable to the workers and artisans or their dependents and children, as the case may be, under the scheme:
 
(1) In case of accidental death of a worker or artisan, a grant of Rs. 1 (One) lakh shall be paid to his legal dependent (s).
 
(2) In case of natural death of a worker or artisan, a grant of Rs. 30,000 (thirty thousand rupees) shall be paid to his legal dependent (s).
 
(3) In case of permanent total disability of a worker or artisan, a grant of Rs. 75,000 (seventy five thousands rupees) shall be paid to him.
 
(4) In case of permanent partial disability of a worker or artisan, a grant of Rs. 37,500 (thirty seven thousands five hundred rupees) shall be paid to him.
 
(5) An amount @ Rs 100 (one hundred rupees) per month, in one yearly installment of Rs 1200/ for 12 months, shall be paid as scholarship to the maximum of two children of a worker or artisan studying in classes 9th to 12th , Government Polytechnics and long term trades in Government Industrial Training Institutes in the State of Bihar. However, if the child fails in an examination, the financial assistance shall not be paid next year to him.
 
(6) In case a worker or artisan suffers injury in an accident causing his hospitalization for a minimum period of five days, he shall be paid a medical assistance of Rs 5000 to take care of his medical and other related expenses.
 
(7) A worker or artisan suffering from incurable diseases prescribed in schedule I of this scheme shall be paid medical assistance to take care of his medical and related expenses at the rates prescribed in the said schedule. However, such medical assistance shall be independent of any other assistance which he may receive under any other scheme framed by the State or Central Government.
 
(8) The payments under the scheme shall be made by way of crossed cheque/ demand draft.
 
### 7. Procedure to avail the benefits under the Scheme.
(1) Death Cases. - (a) Application for grant in cases of natural death and accidental death may be given, as soon as possible from the date of such occurrence, in Form-1 to the concerned Block Development Officer/ Labour Superintendent / District Magistrate. These application forms shall be kept in sufficient number at all district offices/ Sub-divisional offices/ Block offices and Panchayat/municipal offices.
 
(b) In case of non- availability of Form, application may be given on plain paper with all necessary documents.
 
(c) The following documents shall be attached with the aforesaid application:
 
 (i) Residential Certificate of the deceased
 
 (ii) Dependent(s) Certificate issued by the circle officer
 
 (iii) Death Certificate issued by competent authority (In case of accidental death, a certificate issued by a doctor not below the rank of a Government Medical Officer shall be required)
 
 (iv) A copy of the information given in the police station regarding the accident/ Certificate of Mukhiya/Ward Council or regarding the accident if informing police station was not required under law
 
 (v) Death Certificate or Inquest report or panchnama, as the case may be (in case of accidental death only)
 
 (vi) Proof of age of the deceased
 
 (vii) Certificate issued by the concerned Mukhiya/ Ward member of the panchayat/Member of the Panchayat Samitee or the concerned Ward Council or in the urban area, as the case may be, specifying the nature of work, the deceased was engaged in.
 
(2) Disability Cases. - (a) Application for grant in cases of permanent total disability or partial disability may be given, as soon as possible from the date of such occurrence, in Form-2, to the concerned Block Development Officer/ Labour Superintendent / District Magistrate. These forms shall be kept in sufficient numbers at all district offices/ Sub-divisional offices/ Block offices and offices of Panchayats.
 
(b) In case of non- availability of Form-2, application may be given on plain paper with all necessary documents.
 
(c) The following documents shall be attached with the aforesaid application:
 
 (i) Residential certificate
 
 (ii) Proof of Age
 
 (iii) A photograph of the applicant showing his disability condition
 
 (iv) A copy of the information given in the police station regarding the accident or Certificate of Mukhiya/Ward Council or regarding the accident if informing police station was not required under law
 
 (v) Disability Certificate issued by competent authority (a certificate issued by a Government orthopedic surgeon shall be required)
 
 (vi) Certificate issued by the Mukhiya/ Ward member of the panchayat/Member of the panchayat samitee/Ward Council or in case of urban area specifying the nature of work the applicant is/ was engaged in.
 
(3) Scholarship to the Children. - (a) Application for scholarship may be submitted to the Executive Director, Bihar State Labour Welfare Society, Patna, in Form-3, together with required documents, through the Head Master of the High School / Principal of the Intermediate College or the Industrial Training Institute/Polytechnic, as the case may be, in which the applicant is studying. These forms shall be kept in sufficient numbers at all district offices/ Sub- divisional offices/ Block offices/ Panchayat/municipal offices, High Schools/Intermediate Colleges and Industrial Training Institutes/Polytechnics.
 
(b) In case of non- availability of Form-3, application may be given on plain paper with all necessary documents.
 
(c) The Head Master of the High School / Principal of the Intermediate College or the Industrial Training Institute/Polytechnic shall, after checking that the application is in order, forward and recommend the claim to the Executive Director, Bihar State Labour Welfare Society, Patna.
 
(d) The following documents shall be attached with the aforesaid application:-
 
 (i) Proof of age of the parent who is a worker or artisan
 
 (ii) Residential certificate of the parent
 
 (iii) Certificate issued by the concerned Mukhiya/ Ward member of the panchayat/Member of the panchayat samitee or the concerned Ward Council or, as the case may be, specifying the nature of work the parent of the applicant is engaged in.
 
 (iv) Photograph of the parent attested by the concerned Mukhiya/ Ward member of the panchayat/Member of the panchayat samitee or the concerned Ward Council or, as the case may be.
 
 (v) Photograph of the student attested by the Head of the Institution
 
(4) Medical Assistance in case of hospitalization after injury. - (a) Application for grant of medical assistance in case a worker or artisan suffers injury in an accident causing his hospitalization, as soon as possible from the date of such occurrence, shall be submitted in Form-5 to the Labour Superintendent/ District Magistrate. These forms shall be kept in sufficient numbers at all district offices/ Sub- divisional offices/ Block offices and Panchayat/municipal offices.
 
(b) In case of non- availability of Form, application may be given on plain paper with all necessary documents.
 
(c) The following documents shall be attached with the aforesaid application:
 
 (i) Residential Certificate
 
 (ii) Certificate of hospitalization
 
 (iii) Copy of the information given in the police station regarding the accident or Certificate of Mukhiya/Ward Council or in case of urban area, as the case may be, regarding the accident if informing police station was not required under law
 
 (iv) Proof of age
 
 (v) Certificate issued by the Mukhiya/ Ward Member of the panchayat/Member of the panchayat samitee or the concerned Ward Council or in the urban area, as the case may be, specifying the nature of work the applicant was engaged in.
 
 (vi) A self attested photograph of the person showing his injury and hospitalization
 
(5) Medical Assistance in case of incurable diseases. - (a) Application for grant of medical assistance in case a worker or artisan suffers from incurable diseases shall be submitted in Form-6 to the Labour Superintendent/ District Magistrate. These forms shall be kept in sufficient numbers at all district offices/ Sub- divisional offices/ Block offices and Panchayat/municipal offices.
 
(b) In case of non- availability of Form, application may be given on plain paper with all necessary documents.
 
(c) The following documents shall be attached with the aforesaid application:
 
 (i) Residential Certificate
 
 (ii) Certificate of the treating medical attendant/hospital regarding the nature of applicants disease
 
 (iii) Proof of age
 
 (iv) Certificate issued by the Mukhiya/ Ward Member of the panchayat/Member of the panchayat samitee or the concerned Ward Council or in the urban area, as the case may be, specifying the nature of work the applicant is/was engaged in.
 
 (v) A self attested photograph
 
### 8. Disposal of the applications in death and disability cases.
 - The District Magistrate/Labour Superintendent shall, immediately after receipt of the application for grant in death and disability cases, send it to the concerned Block Development Officer for enquiry and report.
 
### 9. (1) On receipt of the application, from the District Magistrate or Labour Superintendent as above or directly from the applicant, as the case may be, for grant in death or disability cases, the Block Development Officer shall immediately proceed to enquire into it.
 
(2) While making the enquiry, the Block Development Officer shall ascertain whether the deceased or the applicant in case of disability was/is a worker or artisan. He will then ascertain the cause of death or disability, age of the diseased or applicant in case of disability, and verify the legal dependent (s) of the deceased and enquire the claim.
 
(3) The enquiry shall be completed by the Block Development Officer within 14 days of the receipt of such application and the enquiry report shall be sent to the District Magistrate or Labour Superintendent, as the case may be, without undue delay.
 
(4) Such enquiry reports will be processed by the District Magistrate or the Labour Superintendent as quickly as possible. If the report is to be processed by the Labour Superintendent, he shall place such enquiry reports with his comments before the District Magistrate for appropriate action.
 
### 10. (1) If the District Magistrate deems fit, he may enquire the claim further either by himself or any senior officer subordinate to him. However, any such enquiry shall be completed within 21 days from the date of the receipt of the said report of the Block Development Officer.
 
(2) If the District Magistrate is satisfied with the enquiry report, he shall decide the claim within 30 days from the receipt of the enquiry report. In case the claim is sanctioned, the payment of the grant shall be made through crossed cheque / demand draft to the dependent (s) of the deceased or the applicant in case of disability upon proper verification. In case, the claim is rejected, information to this effect with reasons shall be sent to the claimant as soon as possible.
 
### 11. A record of applications received/enquired and decisions taken shall be duly maintained in the offices of the Block Development Officers/ Labour Superintendents/District Magistrates.
 
### 12. Disposal of the applications for grant of scholarship to the children.
 - The Executive Director, Bihar State Labour Welfare Society or any other authorized officer shall, immediately after receipt of an application for grant of scholarship, process it. If the claim is sanctioned, the cheque/demand draft of the financial assistance shall be sent to the Head Master/ Principal of the concerned School/College/Institute for making payment to the applicant. In case, the claim is rejected, information to this effect with reasons shall be sent to the claimant through the institution as soon as possible.
 
### 13. The application of scholarship shall be disposed of within 14 days of its receipt in the office of the Society.
 
### 14. The Head Master/Principal of the concerned High School/Intermediate college/Institute shall hand over concerned cheque/demand draft to make available to the respective student(s)  upon proper verification and send the utilization certificate in Form- 4 to the Society.
 
### 15. A record of applications received and decisions taken shall be duly maintained in the office of the Society.
 
### 16. Disposal of the applications for medical assistance in the cases of injury and incurable diseases.
 - Upon receipt of the application for grant of medical assistance in the cases of injury and incurable diseases, the Labour Superintendent/District Magistrate shall process it promptly. If the application has been received by the labour superintendent, he shall after checking that the application is in order submit it with his comments to the District Magistrate for decision.
 
### 17. If the District Magistrate is satisfied with the claim, he shall decide the claim expeditiously. In deciding the claim, the District Magistrate may consult the Chief Medical Officer of the district. However, such consultation should not take undue time.
 
### 18. In case the claim is sanctioned, the payment of the grant shall be made through crossed cheque / demand draft to the applicant upon proper verification. In case, the claim is rejected, information to this effect with reasons shall be sent to the applicant as soon as possible.
 
### 19. The application for grant in case of hospitalization after injury shall be disposed of within 7 days of its receipt.
 
### 20. The application for grant in case of incurable diseases shall be disposed of within 14 days of its receipt.
 
### 21. A record of applications received/enquired and decisions taken shall be duly maintained in the offices of the Labour Superintendents/District Magistrates.
 
### 22. Appeal.
 - A person aggrieved by any order of the District Magistrate or the Society, as the case may be, shall make an appeal before the Labour Commissioner, Bihar whose decision shall be final and binding. The Labour Commissioner shall dispose of all such appeals within 30 days of its filing.
 
### 23. Transparency in disposal of cases.
 - A complete transparency shall be maintained at all levels in disposal of the cases under this scheme.
 
### 24. As a means to maintain transparency, all orders passed by the District Magistrate(s) , Society or Labour Commissioner shall be brought in public domain by uploading the orders on the web site of the concerned districts, Society or Labour Commissioner, as the case may be, as soon as such order is passed.
 
### 25. The list of all beneficiaries shall be uploaded from time to time on the web sites of the concerned districts, Society and the Department of Labour Resources.
 
### 26. Nodal Authority.
(1) Bihar State Labour Welfare Society, which has been established by the State Government under the administrative control of the Department of Labour Resources, shall be the nodal authority for implementing and monitoring the Scheme at the State level.
 
(2) The District Magistrate(s) shall be the nodal authority for implementing and monitoring the Scheme at the district level.
 
(3) Labour Superintendent/ Assistant Labour Commissioner, as the case may be, or any other officer authorized by the District Magistrate(s), shall be the in- charge of the Scheme in the districts. Such officer in charge shall be designated as the District Key Manager.
 
### 27. General.
 - If a worker or artisan has an insurance policy, other than under Aam Aadmi Bima Yojana, he and his dependent (s)  shall not be denied benefit under this Scheme.
 
### 28. All such officers who will fully fail to discharge their duties prescribed under this Scheme shall be liable for disciplinary action.
 
### 29. Removal of Difficulties.
 
 - If any difficulty arises as to the interpretation or implementation of any provisions of this scheme, the Department of Labour Resources shall have the powers to remove difficulties and their decision shall be final and binding.
 
### 30. The Department of Labour Resources shall have the powers to issue instructions from time to time for implementation of the Scheme.
 
### 31. Amendment and Repeal.
 - The State Government shall have the powers to amend or repeal any or all provisions of this scheme.
 
 I
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| 
 List of Incurable Diseases and Rate of Medical
 
 Assistance
  |
| 
 S.No.
  | 
 Name of disease
  | 
 Nature of Treatment
  | 
 Amount of Medical Assistance (Rs) |
| 
 1.
  | 
 Cancer
  | 
 Surgical (with surgery)
  | 
 25000
  |
| 
 | 
 | 
 Non Surgical (without surgery)
  | 
 15000
  |
| 
 2.
  | 
 Heart diseases
  | 
 D.V.R.(Double Valve Replacement
  | 
 30000
  |
| 
 | 
 | 
 M.V.R. (Mitral Valve Replacement)
  | 
 25000
  |
| 
 | 
 | 
 Pace Maker
  | 
 25000
  |
| 
 | 
 | 
 Stenosis/Baloon Valvotomy
  | 
 15000
  |
| 
 | 
 | 
 CABG(Coronary Artery Bypass Grapht)
  | 
 25000
  |
| 
 | 
 | 
 PTCA Percutaneours Transluminous Coronary Angio
 
 Plasty
  | 
 25000
  |
| 
 | 
 | 
 ASD (Atrial Septal Defects)/V.S.D.
  | 
 15000
  |
| 
 3
  | 
 Renal(Kidney)  Disease
  | 
 Surgical (with surgery)
  | 
 30000
  |
| 
 4
  | 
 Brain Tumors
  | 
 Minor Surgery
  | 
 10000
  |
| 
 | 
 | 
 Major Surgery
  | 
 20000
  |
| 
 5
  | 
 AIDS
  | 
 As decided by the medical attendant
  | 
 25000
  |
| 
 6
  | 
 Total Hip or Knee Replacement
  | 
 Surgery
  | 
 10000
  |
| 
 7
  | 
 Major Vascular Surgery
  | 
 Surgery
  | 
 10000
  |
| 
 8
  | 
 Bone Marrow Transplantation
  | 
 Surgery
  | 
 10000
  |
| 
 9
  | 
 Spinal surgery
  | 
 Surgery
  | 
 7500
  |
 Government of Bihar
 
 Department of Labour Resources
 
 Form-1
 
 Claim Form for receipt of grant in the cases of Natural Death/Accidental Death under Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011
 
 (To be submitted in Triplicate to B.D.O/ Labour Superintendent/ District Magistrate\*)
 
### 1. (a)  Name of deceased\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (b)
 
 Age\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (c) Place of work\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (d) Nature of work\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (e) Address- Village/Mohalla\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Panchayat/Ward \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PO\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 P.S \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Anchal/Block \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 District \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 #2. Statement of Accidental Death:
 
 (a) Date of Accident \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (b) Time \_\_\_\_\_\_\_\_\_\_ A.M./P.M.
 
 (c) Place \_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (d) Details of Accident.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (f) Date of Death & Time \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 #3. Statement of Natural death:
 
 (a) Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (b) Time \_\_\_\_\_\_\_\_\_\_ A.M./P.M.
 
 (c) Place \_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (d) Cause of death\_\_\_\_\_\_\_\_\_\_\_\_
 
 (f) Date of Death & Time \_\_\_\_\_\_\_\_\_\_\_\_
 
### 4. Name and Designation of Authority issuing Death Certificate / Post Mortem Report (if applicable) ###
 5. Details of Claimants: The dependent(s)  of the deceased is/are as follows
 (i) Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_Address \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Relation with the deceased\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (ii) Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Relation with deceased \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (iii) Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Relation with deceased\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
### 6. Documents Enclosed: The following documents have been attached with this application- (i) Dependent(s) Certificate issued by Circle Officer ( Anchal Adhikari)
 
 (ii) A copy of the information given in the police station regarding the accident/ Certificate of Mukhiya/Ward Council or regarding the accident if informing police station was not required under law
 
 (iii) Death Certificate or Inquest report or panchnama, as the case may be (in case of accidental death only)
 
 (iv) Residential certificate of the deceased
 
 (v) Proof of Age of the deceased
 
 (v) Certificate issued by the Mukhiya/ Ward member of the panchayat/Member of the panchayat samitee/Ward Council or in case of urban area specifying the nature of work the deceased was engaged in.
 
 I / We declare that above information is correct to the best of my/our knowledge.
 
 I / We declare that if any information is found to be false, my/our claim shall be deemed illegal and I/we shall be prosecuted under law.
 
 Witnesses
 
|  |  |
| --- | --- |
| 
 1. Name & Address
  | 
 1-
  |
| 
 (a) | 
 2-
  |
| 
 (b) | 
 3-
  |
| 
 | 
 ------
  |
| 
 ------
  | 
 |
 Signature of Claimant(s) \*One copy with acknowledgement shall be returned to the applicant
 
 # Strike off if not applicable
 
 Office of the Block Development Officer\_\_\_\_\_\_
 
 District\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Enquiry Report
 
 (a) Genuineness of the dependent(s):
 
 (b) Opinion regarding cause of death:
 
 (c) Whether the deceased was a worker engaged in unorganized sector/artisan as defined under the rules? Yes/No
 
 (e) If yes, what kind of work he was engaged in?
 
 (f) Age of the deceased
 
 The claim was enquired by me. The enquiry report is enclosed. I recommend that the claim may be sanctioned / rejected on the following grounds:
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Place: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Signature of B.D.O
 
 Seal
 
 Office of the District Magistrate\_\_\_\_\_\_\_\_\_\_
 
 The claim was enquired by \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (Name of the Officer) and his findings are acceptable/not acceptable. The claim is sanctioned and it is ordered that the dependent(s)  be paid Rs.. under the Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011 / the claim is rejected on the following grounds:
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Labour Superintendent/
 
 Assistant Labour Commissioner
 
 Or
 
 an officer authorised by the District Magistrate
 
 Place: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Date:- \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Signature of District Magistrate
 
 (Seal) The dependent (s) Shri., Shri, Shrihas been paid Rs.. on dated .vide Cheque/Demand Draft No dated..drawn on Bank.
 
 Signature and seal of the authorized signatory
 
 Government of Bihar
 
 Department of Labour Resources
 
 Form-2
 
 Claim Form for receipt of grant in the cases of Total permanent/partial disability under Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011
 
 (To be submitted in Triplicate to B.D.O/ Labour Superintendent/ District Magistrate\*)
 
### 1. (a)  Name of the claimant\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (b)
 
 Age\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (c) Place of work\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (d) Nature of work\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (e) Address- Village/Mohalla Panchayat/Ward \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ PO\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 P.S \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Anchal/Block \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 District \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
 
### 2. Statement of Accident: (a) Date of Accident \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (b) Time \_\_\_\_\_\_\_\_\_\_ A.M./P.M.
 
 (c) Place \_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (d) Details of Accident.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
### 3. Statement of Disability: (a) Details of disability \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (b) Type of disability: Total permanent/partial disability
 
### 4. Name and Designation of the Authority issuing Disability Certificate: ###
 5. Documents Enclosed: The following documents in respect of the claimant have been attached with this application-
 (i) Residential certificate
 
 (ii) Proof of Age
 
 (iii) A photograph of the applicant showing his disability condition
 
 (iv) A copy of the information given in the police station regarding the accident/ Certificate of Mukhiya/Ward Council or regarding the accident if informing police station was not required under law
 
 (v) Disability Certificate issued by competent authority (a certificate issued by a Government orthopedic surgeon shall be required)
 
 (vi) Certificate issued by the Mukhiya/ Ward member of the panchayat/Member of the panchayat samitee/Ward Council or in case of urban area specifying the nature of work the applicant is/ was engaged in.
 
 I declare that above information is correct to the best of my knowledge.
 
 I declare that if any information is found to be false, my claim shall be deemed illegal and
 
 I shall be prosecuted under law.
 
 Witnesses
 
### 1. Name & Address (a) (b)
 
 Signature of the Claimant
 
 \*One copy with acknowledgement shall be returned to the applicant
 
 Office of the Block Development Officer\_\_\_\_\_\_\_
 
 District\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Enquiry Report
 
 (a) Genuineness of the claimant: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (b) Opinion regarding cause of disability: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (c) Opinion about type of disability: Total permanent disability/partial disability
 
 (d) Whether the claimant is/was an unorganized sector worker /artisan? Yes/No
 
 (e) If yes, what is the nature of his work ?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (f) Age of the claimant\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 The claim was enquired by me. The enquiry report is enclosed. I recommend that the claim may be sanctioned / rejected on the following grounds:
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Place: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Signature of B.D.O
 
 (Seal) Office of the District Magistrate\_\_\_\_\_\_\_\_\_\_
 
 The claim was enquired by \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (Name of the Officer) and his findings are acceptable/not acceptable. The claim is sanctioned and it is ordered that the claimant be paid Rs.. under the Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011/ the claim is rejected on the following grounds:
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Labour Superintendent/
 
 Assistant Labour Commissioner
 
 or
 
 an officer authorised by the District Magistrate
 
 Place: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Date:- \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Signature of District Magistrate
 
 (Seal) The claimant Shri., r/o has been paid Rs.. on dated .vide Cheque/Demand Draft No dated..drawn on Bank.
 
 Signature and seal of the authorized signatory
 
 Government of Bihar
 
 Department of Labour Resources
 
 Form-3
 
 Form for receipt of scholarship under Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011
 
 (To be submitted in Triplicate to Head Master/Principal of the High School/Intermediate College/ Government ITI/ Government Polytechnics\*)
 
 To,
 
 The Executive Director
 
 Bihar State Labour Welfare Society
 
 Department of Labour Resources
 
 Patna, Bihar
 
 Through,
 
 The Head Master/Principal
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (Name of the Institution)
 
 Sir,
 
 I am making this application for grant of scholarship under Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Rules, 2011. My father/mother is an unorganized sector worker/artisan. I am a student of class/trade/discipline\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ in the High School/Intermediate College/ITI/Polytechnic \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
 
 My particulars are as follows:
 
### 1. Name \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ###
 2. Father/Mothers Name & Age\_\_\_\_\_\_\_\_\_\_\_\_\_\_
### 3. Father/Mothers Complete Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ###
 4. Occupation of Father/Mother\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
### 5. Name of brothers/Sisters, if any, getting scholarship under this scheme\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ###
 6. Following documents are enclosed with this application
 i. Residence Certificate of Father/Mother
 
 ii. Affidavit regarding number of brothers and sisters of the applicant and whether they are getting scholarship under the scheme
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 iii. Certificate issued by Mukhiya/Panchayat Ward Member/ Member Panchayat Samity/Ward Council or in case of urban areas specifying the nature of work the father/mother of the applicant is engaged in.
 
 iv. Photograph of the father/mother attested by the concerned Mukhiya/ Ward member of the panchayat/Member of the panchayat samitee or the concerned Ward Council or, as the case may be.
 
 v. Photograph of the applicant attested by the Head of the Institution.
 
 I certify that all particulars given above are true to the best of my knowledge.
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 I declare that if any information is found to be false, my claim shall be deemed illegal and
 
 I shall be prosecuted under law.
 
 Signature of the applicant
 
 Date:
 
 Place:
 
 Office of the Head Master/Principal of High School/Intermediate College/Industrial Training Institute/Polytechnic \_\_\_\_\_\_\_\_\_\_\_\_\_\_District\_\_\_\_\_
 
 This is certified that the above mentioned applicant Shri/Kumari \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_s/d/o Shri/Smt \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ r/o\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is a student of class/Trade/discipline \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_of my institution. I have verified from the certificates furnished by him that he/she is son/daughter of an unorganized sector worker/artisan. The particulars furnished by him/her are true to the best of my knowledge.
 
 I recommend and forward this application for grant of scholarship to him/her as per existing provisions made under Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011.
 
 Name and signature of the Head Master/Principal
 
 ( )
 
 Date:
 
 Place:
 
 Seal of the Institution
 
 \*One copy of the application shall be returned to the applicant after acknowledging.
 
 Government of Bihar
 
 Department of Labour Resources
 
 Office of the Bihar State Labour Welfare Society Patna, Bihar
 
 The application of Shri/Kumari \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_s/d/o Shri/Smt \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_r/o \_\_\_\_\_\_\_\_\_\_\_\_\_ who is a student of class/Trade/discipline \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_in \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (Name and address of the Institution) received vide Head Master/Principal letter no. \_\_\_\_\_\_\_\_\_\_dated \_\_\_\_\_\_\_\_\_\_\_has been examined. His/her application for grant of scholarship under Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011 is sanctioned/rejected on following grounds: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 #The applicant is eligible to get scholarship @ Rs 100 per month under the scheme. The yearly installment amounting to Rs 1200 is sanctioned.
 
 Name and signature of the sanctioning authority
 
 ( )
 
 Date:
 
 Place:
 
 Office Seal
 
 Cheque/ DD No. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_dated \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_drawn on Bank \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Branch \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_amounting to Rs\_\_\_\_\_\_\_\_\_issued in the name of Shri/Kumari \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_S/D/o Shri/Smt \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_sent to Head Master/Principal of (Name of the Institution) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_on dated \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ by registered post for making payment to him/her upon proper verification.
 
 Name and signature of Accountant/Accounts Officer
 
 ( )
 
 # Delete if not applicable
 
 Office of the Head Master/Principal of High School/Intermediate College/Industrial Training Institute\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Form-4
 
 Utilization Certificate regarding payment of scholarship under Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011
 
 This is to certify that a cheque/DD No.\_\_\_\_\_\_\_\_\_\_\_\_ Dated\_\_\_\_\_\_\_\_\_\_\_\_\_ ,received from the Bihar State Labour Welfare Society, drawn on Bank \_\_\_\_\_\_\_\_\_Branch \_\_\_\_\_\_\_\_\_\_\_\_\_ amounting to \_\_\_\_\_\_\_\_\_\_\_\_ issued in favour of Shri/Kumari \_\_\_\_\_\_\_\_\_\_\_ S/D/o Shri/Smt \_\_\_\_\_\_\_\_\_\_ of class/trade/discipline \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ of this institution has been paid to him/her upon proper verification.
 
 Name and signature of the Head Master/Principal
 
 ( )
 
 Seal
 
 Government of Bihar Department of Labour Resources
 
 Form-5
 
 Application for Medical Assistance in the cases of hospitalization after injury under Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011
 
 (To be submitted in triplicate to Labour Superintendent/ District Magistrate\*)
 
### 1. (a)  Name of the claimant\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (b)
 
 Age\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (c) Place of work\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (d) Nature of work\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (e) Address- Village/Mohalla PO \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Panchayat/Ward\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 P.S \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Anchal/Block \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 District \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
### 2. Statement of Accident/hospitalization: (a) Date of Accident \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (b) Time \_\_\_\_\_\_\_\_\_\_ A.M./P.M.
 
 (c) Place \_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (d) Details of Accident.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (e) Name and full address of the hospital where admitted for treatment \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (e) Date of admission in the hospital\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (f) Date of discharge from the hospital\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (g) Total period of hospitalization\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
### 3. Certificate of the attending physician/surgeon: This is to certify that Shri \_\_\_\_\_\_\_\_\_\_\_\_Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ was injured in an accident and was admitted in the hospital\_\_\_\_\_\_\_\_\_\_\_\_ (name of the hospital) under my treatment. He remained under treatment in the hospital for \_\_\_\_\_\_\_\_\_days. Details of his injuries are as below: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
### 4. Documents Enclosed: The following documents have been attached with this application- (i) Residential Certificate
 
 (ii) Discharge certificate issued by the hospital
 
 (iii) Copy of the information given in the police station regarding the accident or Certificate of Mukhiya/ward member of the panchayat/ward commissioner in case of urban area, as the case may be, regarding the accident if informing police station was not required under law
 
 (iv) Proof of age
 
 (v) Certificate issued by the Mukhiya/ Ward Member of the panchayat/Member of the panchayat samitee or the concerned Ward Commissioner in the urban area, as the case may be, specifying the nature of work the applicant is/ was engaged in.
 
 (vi) A self attested photograph of person showing his injury and hospitalization
 
 I declare that above information is correct to the best of my knowledge.
 
 I declare that if any information is found to be false, my claim shall be deemed illegal.
 
 Witnesses
 
### 1. Name & Address (a) (b)
 
 Signature of Claimant
 
 \*One copy with acknowledgement shall be returned to the applicant
 
 Office of the District Magistrate\_\_\_\_\_\_\_\_\_\_
 
 The claim has been examined and found correct/incorrect. The claim is sanctioned and it is ordered that the claimant be paid Rs.. under the Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011 / the claim is rejected on the following grounds:
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Labour Superintendent/
 
 Assistant Labour Commissioner
 
 or
 
 an officer authorised by the District Magistrate
 
 Place: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Date:- \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Signature of District Magistrate
 
 (Seal) The claimant Shri., r/o has been paid Rs.. on dated .vide Cheque/Demand Draft No dated..drawn on Bank.
 
 Signature and seal of the authorized signatory
 
 Government of Bihar
 
 Department of Labour Resources
 
 Form-6
 
 Application for Medical Assistance in the cases of Incurable Diseases under Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011
 
 (To be submitted in triplicate to Labour Superintendent/ District Magistrate\*)
 
### 1. (a)  Name of the claimant\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (b)
 
 Age\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (c) Place of work\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (d) Nature of work\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 (e) Address- Village/Mohalla PO \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Panchayat/Ward\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 P.S \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Anchal/Block \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 District \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
### 2. Statement of Incurable Disease: ###
 4. Name and Address of the treating hospital/doctor (if applicable)
### 5. Documents Enclosed: The following documents have been attached with this application- (i) Residential Certificate
 
 (ii) Certificate of the treating medical attendant/hospital regarding the nature of applicants disease
 
 (iii) Proof of age
 
 (iv) Certificate issued by the Mukhiya/ Ward Member of the panchayat/Member of the panchayat samitee or the concerned Ward Council or in the urban area, as the case may be, specifying the nature of work the applicant is/was engaged in.
 
 (v) A self attested photograph
 
 I declare that above information is correct to the best of my knowledge.
 
 I declare that if any information is found to be false, my claim shall be deemed illegal and
 
 I shall be prosecuted under law.
 
 Witnesses
 
### 1. Name & Address (a) (b)
 
 Signature of Claimant
 
 \*One copy with acknowledgement shall be returned to the applicant
 
 Office of the District Magistrate\_\_\_\_\_\_\_\_\_\_
 
 The claim has been examined and found correct/incorrect. The claim is sanctioned and it is ordered that the claimant be paid Rs.. under the Bihar Shatabdi Unorganized Sector Workers and Artisans Social Security Scheme, 2011 / the claim is rejected on the following grounds:
 
 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 Labour Superintendent/
 
 Assistant Labour Commissioner
 
 or
 
 an officer authorised by the District Magistrate
 
 Signature of District Magistrate (Seal) Place\_\_\_\_\_\_\_\_\_\_\_\_
 
 Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_
 
 The claimant Shri., r/o has been paid Rs.. on dated .vide Cheque/Demand Draft No dated..drawn on Bank.
 
 Signature and seal of the authorized signatory.
 

