Disability Benefits form

Checklist of the documents required for Disability Benefit Form.

1. ABOCWWB Id Card
2. Applicant's Photo
3. Upload Medical Bills Countersigned By Govt Doctor
4. Signature of the Applicant
5. Employer's Certificate On Accident
6. Document Of Admission and Discharge From The Hospital
7. Permanent Disability Certificate From The Appropraite Authority
8. Copy Of Payslip Of Account Paybook
9. Caste Certificate (Other than General category)
11.Photograph Of The Part Of The Person Effected Due To The Accident
12. Any Other Related Documents
13. Loan Recovery Documents

All * Textbox are mandatory

Date*

District Office *

Upload Photo*

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Maximum File size allowed is 1MB
Only png and jpeg images allowed

Name Of The Applicant*

Gender*

Male Female

Mobile Number*

Address*

Age*

Caste Category *

Date of Birth Of The Student*

Name Of The Father/Mother*

Registration Number Of The Father/Mother*

Date Of Registration Of The Father Mother*

Id Card*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Details Of Monthly Contribution

#	Date Of First Payment Of Contribution	Date Of Last Payment Of Contribution	Name Of The Branch Of Bank Where Remitted The Contribution
1

Details Of The Disease/accident*

Nature Of The Disability Due To The Disease/Accident*

Details Of The Treatment In Govt Hospital*

Date Of Admission In The Hospital*

Date Of Discharge*

Whether The Patient Was In Plaster?*

No Yes

Amount Spent For Treatment*

Upload Medical Bills Countersigned By Govt Doctor*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Details Of Benefit Received Earlier,If Any*

Details Of Benefit Received From The Govt Or Any Other Institution For The Above Treatment*

Whether Any Loan/Advance Received From The Board Earlier*

No Yes

Whether The Aforesaid Amount Is Completely Recovered*

No Yes

Name Of The Bank Where Cash Amount to be Deposited*

Address Of Bank*

Account No*

IFSC Code *

Attested Copy Of Id Card*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Employer's Certificate On Accident*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Document Of Admission and Discharge From The Hospital*

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Maximum File size allowed is 1MB
Only pdf,png and jpeg images allowed

Copy Of Payslip Of Account Paybook*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Caste Certificate*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Medical Bills Countersigned By Govt Doctor*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Details Of Family Members

SL No.	Name	Relationship	Age
1

Permanent Disability Certificate From The Appropriate Authority*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Photograph Of The Part Of The Person Effected Due To The Accident*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Any Other Related Documents*

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Maximum File size allowed is 1MB
Only pdf,png and jpeg images allowed

Loan Recovery Documents*

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Maximum File size allowed is 1MB
Only pdf, png and jpeg images allowed

Original Application Form Of Registration*

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Signature Of The Applicant*

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Declaration*