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State of Chattisgarh - Section

Section 9 in Chhattisgarh State Ex-Gratia Compensation Payment for Officials/Employees died or injured during Electioneering Duty, Rules, 2009

9. Power to amend rules.

- State Government is empowered to amend these rules as may be required from time to time.Appendix I[Rule 3]Claim FormOn the happening of Accident this form along with complete medical report should be submitted to Collector and District Election Officer concurred without its support no claim will be entertained.
Claim No. Date of Submission
1. Name if Full  
  (A) Age of Deceased -  
  (B) Residential Address -  
  (C) Official Address -  
2. (A) Day, Date and time of the Accident onward  
  (B) Place of Accident  
  (C) Reasons of Accident and details of injuries  
3. Name and Address of the Hospital where treated.  
I hereby declare that Death/Temporary/Permanent disability is true and I solemnly affirm and give my confront that if I have submitted any false statement, suppressed the, any fact then I will be finally departed from the Right of Ex-gratia compensation granted in this case.I hereby ready to accept the Election Official Ex-gratia for Rs....................as decided by the State Government and therefore preferred the claim.Signature................................Name of Official..........................or Legal Heir.............................RecommendationCertified that the information as advanced by the individual concerned is true therefore the payment of Rs...................is hereby recommended.
(Signature)Collector
District Election OfficerDistt....................Appendix II[Rule 4]Form of Medical ReportNote. - This form should invariably be duly tilled up by the medical Attendant of the claimant.
1. Name in full of the claimant........... Age............
2. Reason of accident as per your knowledge  
3. A. After injury when the claimant was treatedfirst. B. Did you still continuing the treatment of claimant.  
4. Are you personal doctor of the claimant if yesplease quote the period from which claimant is known to you andwhich disease you have treated  
5. Did injuries arerelated to..........(A) Only due toAccidentor(B) Related with disease or any other reason (A)(B)
6. Any other remark  
I hereby write that above mentioned person is victim of Accident and the or this report are true.
(Signature)Name of Doctor
Address