CHAPTER 1 - Border Roads Organisation

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Appendix “D”
CERTIFICATE FOR DEATH/INVALIDMENT CASES
1. It is certified that Ex/GS ____________________ Trade __________________
Name _____________________________________ of _______________________________
(unit) died/was medically boarded out on _______________________ due to
__________________________________ (name of disease) while on duty/leave.
2. He is covered/not covered by WCA 1923.
3. He is eligible for compensation in terms of Chapter I of Sec 2 (I) (n) of Schedule II and
Chapter II, Sec 3(I) read with parts A to C of Schedule III of WCA-1923 and the same has been
paid/being paid to his NOK.
4. He is not eligible for compensation under WCA as cause of death does not fall under the
provisions of Chapter I of Sec 2 (I) (n) of Schedule II and Chapter II, Sec 3 (I) read with parts
A to C schedule III of WCA, 1923, hence the compensation has not been paid to NOK.
Station :
(with round stamp)
Dated : (Signature of OC Unit)
191
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