Form No.: SEP-CSSS-02 (To be filled by claimants for release of Annual Installment i.e.

10% of admissible support amount under CSS Scheme)

OIL AND NATURAL GAS CORPORATION LIMITED

APPLICATION FOR FINANCIAL ASSISTANCE IN CASE OF

DEATH/ PERMANENT DISABILTY UNDER COMPOSITE SOCIAL
SECURITY SCHEME (CSSS) OF ONGC.

Please read instructions placed at page 4 of the enclosures at the end of claim form.

(1) Full Name of Deceased employee: -----------------------------------------------------------------

(2) CPF NO: -------------------------------Designation:---------------------------------------------

(3) Claim submitted for (Tick the appropriate box) : First Installment Second
Installment Third Installment Fourth Installment Fifth Installment

(4) Details related to Claimant (s)

Name-----------------------------------------------------Date of Birth------------------------
Relationship of claimant with the deceased---------------------------------------------------------
Address --------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------
Contact No. --------------------------------------------PAN No.-------------------------------
(5) NOC for receipt of Support amount under CSSS by either of father or mother of deceased
employee: (This NOC is required if parents are not nominated and both are surviving. If only
mother or father of deceased employee is surviving, the declaration is not required)

a) I have no objection for receipt of Support amount under CSSS by-----------------------------

---------------------------- (name of Recipient).

(To be signed by mother of deceased employee, if father is recipient of support amount under
CSSS and vice versa)

(Signature/thumb impression of Mother/Father)

OR

b) We want to take support amount separately.

(Signature/thumb impression of Father) (Signature/thumb impression of Mother)

(6) Details of Bank Account
Name of
Claimant/Account Holder
Name of Bank
Account no.
IFSC Code
Name and address of
Branch

(7) Certified that:-

(a) I am/ we are eligible for support under CSSS of ONGC.

(b) Particulars given above are true to the best of my/ our knowledge and belief.
(c) The Support under CSSS be paid to me/ us.

Date:
(Signature/thumb impression of Claimant)

Place:

Certified that all above details of claimant(s) have been verified from his/her personal file and
cross checked with available records/system and that claimant(s) is/are eligible for support under
ONGC CSS Scheme.

Date :____________________ (Head of concerned Establishment

with Designation and official seal)
 Life Certificate
(For release of annual installment under ONGC CSS Scheme)

This is to certify that Shri/Smt._________________________________, wife/ Son/

Daughter/ Father/Mother/Legal heir of late___________________________________, CPF
no. __________________, Designation______________________ personally appeared
before me and has signed in my presence on dated______________________.

Signature/Thumb Impression of beneficiary. Certified by

Address: __________________________

___________________________ (Signature with seal)

___________________________
Name_______________________

Mobile no. ________________________ Designation: _________________

Note: Life certificate of claimant (s) must be certified by Manager of nationalized bank OR at least
E2 level active employee of ONGC.
FOR CLAIMANT

Instruction and checklist for filling claim form:

1. Claim form –SEP-CSSS-02 should be used for release of Annual Instalment (i.e. 10% of
admissible support amount under CSS Scheme) and NOT for release of Initial payment.
All entries may be filled in HINDI or ENGLISH Language.

2. All information should be correctly filled in. Please clearly mention NOT
APPLICABLE wherever it is not required.

3. In case of more than one claimant, use additional sheet.

4. Please ensure that the following documents have been enclosed along with Claim form
SEP-CSSS-02 for release of Annual instalment (i.e. 10% of admissible support amount
under CSS Scheme)

Sl. Particulars Tick ( )

No. if
applicable
,otherwise
indicate
N.A.
1 Copy of life certificate of claimant (s) (Must be certified by Manager of
nationalized bank OR at least E2 level active employee of ONGC)

2 Death certificate of parent of deceased employee issued by local

authority. (If nominee claims that parents are not alive and died before
the submission of this claim)

3 Self-attested copy of bank passbook or bank statement (showing receipt

of immediate previous payment from CSSS Trust).

4 Copy of cancelled cheque or front page of bank passbook, if claimant

has changed the bank details submitted earlier.

5 Self-attested copy of address proof, if there is change in address as

mentioned earlier in claim form.
 FOR ESTABLISHMENT OFFICER

i. Duplicate copy of the Application Form is to be retained in personal file of the individual
and the original is to be forwarded to CSSS Trust, Dehradun.
ii. Before forwarding the claim form to the CSSS Trust, Dehradun, please ensure that

Sl. Particulars Tick ( )

No. if
applicable
,otherwise
indicate
N.A.
1. All entries of Claim form have been duly filled by claimant(s).

2. Claim created in SAP has been forwarded to CSSS Trust.

3. Claim form is certified by head of concerned establishment properly.

4. Copy of life certificate of claimant (s) (Must be verified by Manager of

nationalized bank OR at least one E2 level active employee of ONGC)
5. Death certificate of parent of deceased employee issued by local
authority. (If nominee is claiming that parents are not alive and died
before the submission of this claim)
6. Self-attested copy of bank passbook or bank statement (showing receipt
of immediate previous payment from CSSS Trust).
7. Copy of cancelled cheque or front page of bank passbook, if claimant has
changed the bank details submitted earlier.
8. Self-attested copy of address proof, if there is change in address as
mentioned earlier in claim form.