Application for Claiming of relief for “Natural Death” Case under BOCW Act. Registration No. of the worker with date: i is Affix ALO Circle No : Applicant Photo Renewed up to : Challan No. Date amount 4. Name of the deceased Construction Worker a) Date of Death : b) Place of death 2. Name of the authority issued the death certificate 3. Name of the person applied for the benefit of the scheme a) Age b) Address ©) Phone No. 4d) Caste 2 SC /ST/ BC/ Minority / others Relationship with the deceased worker: &. Name of family members / dependents 6. Bank Account No. a) Name of the Bank with Branch b) IFSC Code No. Date Station : Documents submitte 1) Regn card under BOCW Act (Original) Signature / Thumb impression 2) Renewal Challan Copy 3) Death Certificate of te Applicant 4) Advance stamped receipt '5) 1st page of Bank Pass Book (Attested copy)