1. The I.M.

O Incharge
E.S.I Service Dispensary
Binnaguri, Jalpaiguri

2. Government Of West Bengal

OFFICE OF THE ADMINISTRATIVE MEDICAL OFFICER
EMPLOYEES' STATE INSURANCE (MEDICAL BENEFIT) SCHEM
P- 233, C.I.T. SCHEME VII- M
BAGMARI ROAD, KOLKATA- 700054

3. M/S O.P. INDUSTRIES

Vill. JATIAKALI, PO- FULBAR HAT,

DIST: JALPAIGURI WEST BENGAL 99999

sub : prayer for disbersment of E.S.I in favour of Mamta Begum.

sir,

under instruction from my cliant Mamta Begum, W/O - Tohijul Md recidence of

Vill.Jatiakali, Fulbari, Siliguri, Dist. Jalpaiguri, West Bengal. I do here by infrom you that my cliant
is an employe under the O.P No. 3 and in the year of 2014 an accident took place while my cliant
working in the factory.

That due the said accident my cliant prayed for compensation and other money which my
cliant entitle to and submitted all papers to the compitent authority. Copy of the said papers is
annexed herewith annexure A of this prayer.

In the aforsaid circumstances you are requested to

pay the E.S.I along with other benifit to my cliant. within
fifteen(15)dayes of receive of this prayer.
 with regard

ChanchaL Advocate.

Copy to the I/C Bhaktinagar.

Enclose as stated about.