Medical Assistance form

Checklist of the documents required for Medical Assistance Benefit Form.

1. ABOCWWB Id Card
2. Bank passbook first page
3. Copy Of Payslip Of Account Paybook Showing Monthly Contribution Deposited
4. Accident Report From The Employer/Principal Employer/Local Police Authority
5. All Documents Of Treatment In Govt Hospital Upload 1
6. Photo Of The Part Of The Person Effected Due To Accident
7. Percentage Of Disability Certificate From The Appropriate Authority
8. Signature

All * Textbox are mandatory

Date*

District Office *

Name Of The Applicant*

Mobile Number*

Address*

Registration No*

Date of Registration*

Id Card*

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Maximum File size allowed is 1MB
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Age*

Date of First Payment Of Contribution*

Date of Last Payment Of Contribution*

Total Amount Of Contribution Remitted*

Details Regarding Disease/Surgery/Accident*

Disability If Any Due To The Disease/Surgery/Accident

Name Of The Govt Hospital*

Hospital Address Were Admitted*

Period Of Treatment As Indoor Patient In Govt Hospital*

Date of Admission In The Hospital*

Date of Discharge In The Hospital*

Details Of Medical Benefit Received If Any, Earlier*

Name Of The Bank Of The Applicant*

Account No Of The Applicant*

Bank Branch Name

Bank IFSC Code

Attested Copy Of Id Card*

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Only pdf,png and jpeg images allowed

Bank passbook first page*

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Only pdf,png,jpeg images and pdf file type allowed

Copy Of Payslip Of Account Paybook Showing Monthly Contribution Deposited*

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

Accident Report From The Employer/Principal Employer/Local Police Authority*

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

All Documents Of Treatment In Govt Hospital Upload 1*

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All Documents Of Treatment In Govt Hospital Upload 2*

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All Documents Of Treatment In Govt Hospital Upload 3

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Photo Of The Part Of The Person Effected Due To Accident

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

Percentage Of Disability Certificate From The Appropriate Authority

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Declaration*

Signature*

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