Appendix ‘A’ Application Regn No ________________ Place of Issue : _______________ APPLICATION FORM FOR ENROLMENT INTO EX-SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS) To, The Director Ex-Servicemen Contributory Health Scheme (ECHS) Regional Centre ____________________ Sir, I wish to voluntarily enrol myself as a member of the “Ex-Servicemen Contributory Health Scheme(ECHS)”, applicable to retired Armed Forces personnel drawing Service/disability Pension or widows/dependants of Ex-Servicemen drawing Family Pension. My personal particulars and details of my family members for whom I wish to avail medical facilities of the ECHS are noted below for reference:- PARTICULARS OF PENSIONER (a) Service No _____________________________________ (b) Rank _____________________________________ (c) Name in Full _____________________________________ (d) Regt/Corps/Unit _____________________________________ (e) Date of Birth _____________________________________ (f) Permanent Address _____________________________________ _____________________________________ _____________________________________ _____________________________________ (g) Telephone No _____________________________________ (h) Date of retirement /discharge _______________________________ ______ (j) Record Office _____________________________________ (k) Pension Payment Order No _____________________________________ and particulars (l) Identification mark(s) _____________________________________ FAMILY DETAILS (a) Name of Spouse _____________________________________ (b) Date of marriage _____________________________________ (c)Date of Birth of Spouse ______________________________________ (d)Details of dependants and dependant parents as under : - Ser Name Date of Relationship Identification Marital Employed/ Mention in No Birth Mark(s) Status Not Discharge Employed book * (Yes/No) 1 2 3 4 5 6 ) Note : *( Indicate monthly income of dependant parents – It is mandatory to fill this column if dependant parents are desired to be included in ECHS Coverage. 2 Details of MRO Payment Basic Pension Rates of Subscription Bank___________________________ Upto Rs 3000 -Rs 1800 Branch__________________________ Between 3001-6000 -Rs 4800 MRO No_________________________ Between 6001-10000 -Rs 8400 Dated____________________________ Between 10001-15000 -Rs 12000 Amount Rs_______________________ Above 15000 -Rs 18000 (________________________________ (Note: Basic Pension excluding DA) _________________________________) Attested Affidavit along with one photograph each of self and each dependants is enclosed. Certified that the particulars given above are correct in all respects. In case it is discovered at any stage by the ECHS that any of the above particulars given is false, my membership and that of my dependants will be automatically terminated and MRO money forfeited, without any further reference/relief. I hereby agree to abide by the Rules prescribed by the ECHS for the above Scheme, as may be amended from time to time. Yours faithfully, Place: Signature of Ex-Servicemen/Widow applicant (Thumb impression of widow Date: if illiterate, duly attested by Class I Officer) PART II (FOR USE BY STN HQ’s) Original documents checked & photocopy verified and retained 1. PPO Yes/No Certified that particulars given above have been 2. Discharge Book Yes/No verified and are correct in all respects. 3. ESM Identity Card Yes/No Documents enclosed 4. Affidavit Yes/No 5. Passport Size Photo of Yes/No self and all dependents 6. Copy of MRO Yes/No (Signature of SSO Stn HQ’s) Date : _________________ PART III Enclosures- Tickmark (FOR USE BY REGIONAL CENTRE ) MRO Yes/No CHECK LIST Affidavit Yes/No 1. Documents Checked. Photograph Yes/No 2. Entry Made in Master Register. (of all members) Date : (Signature of Supdt) APPROVED/NOT APPROVED Particulars of Card issued – (a) ECHS Card No________________(b) Date of issue_____________ Date: (Signature of Regional Director) RECIEPT OF CARD Dated : (Signature of Pensioner) 3 Affix Passport size PERSONAL NO : Photo of PENSIONER against light RANK & NAME : background (in block capitals) PPO NO : ADDRESS : RECORDS OFFICE : Signature of Pensioner Affix Passport Affix Passport Affix Passport Affix Passport size Photo size Photo size Photo size Photo against light against light against light against light background of background of background of background of SPOUSE of CHILD of CHILD of CHILD of Pensioner Pensioner Pensioner Pensioner Name Name Name Name Date of Birth Date of Birth Date of Birth Date of Birth Employed/ Not Employed Employed/ Not Employed Employed/ Not Employed Married/Not Married Married/Not Married Married/Not Married Affix Passport size Affix Passport Affix Passport Affix Passport Photo against light size Photo size Photo size Photo background of against light against light against light CHILD of background of background of background of Pensioner CHILD of FATHER of MOTHER of Pensioner Pensioner Pensioner Name Name Name Name Date of Birth Date of Birth Date of Birth Date of Birth Employed/ Not Employed Employed/ Not Employed Married/Not Married Married/Not Married VERIFIED BY ECHS NO Station Headquarter (to be given by Regional Headquarter ECHS) Signature of verifying Offr at Station Stamp of verifying Offr at Date : Headquarter Station Headquarter AUTHORISED BY Signature of authorising Offr at Stamp of authorising Offr at Regional Regional Headquarter ECHS Headquarter ECHS 4 AFFIDAVIT ON Rs. 10/- NON JUDICIAL STAMP PAPER AND ATTESTED BY A MAGISTRATE/NOTARY PUBLIC DECLARATION I, Service No ____________ Rank ___________ Name _______________________________________________________ of (Unit) ___________________________, solemnly affirm and declare as follows:- 1. That I am drawing pension vide CDA (P) Pension Payment Order No. _________________________ dated ____________. 2. That I have the following legal dependant(s) whose photograph(s) is/are affixed on this affidavit:- Name Relationship Age Date of Birth Part II Order No/Gen Form/AF Order Signed photo of Dependent giving name, Signed photo of Dependent giving name, relationship and Identification mark. Relationship and Identification mark. (Photograph(s) to be pasted on Affidavit & signed across by each applicant. In case of child/minor to be signed by applicant) 3. That the monthly income of my dependant father and/or dependant mother from all sources is less than Rs 1500/- each. 4. That my son(s) is/are under the age of 25 year s and is/are not employed and that my daughter(s) are not employed or married. 5. That I am aware of the fact that my sons are not eligible for the Ex-servicemen Contributory Health Scheme after they attain 25 years of age or get employed at any time before that age. 6. That I am aware of the fact that my daughter(s) is/are not eligible for the Ex servicemen Contributory Health Scheme after she/they marry or get employed. 7. That in case of any change in the status of my dependents (due to death, marriage, employment), I will inform my Regional Headquarters ECHS at the earliest and will stop use of ECHS facility. I will refund in full the cost of any treatment that a dependent may have received after he/she became ineligible for the same. I shall be liable for civil/criminal action should I fail to do so. 8. That I am not a member of any medical scheme funded by the Central Government, Public Sector Undertaking or any other Government Undertaking. 9. That, in case I have submitted any fraudulent information or if my ECHS Membership Card is misused/used by any unauthorized person, my membership will automatically be cancelled and I will forfeit my contribution. I will also be liable for legal action by the ECHS Organisation. That, I will immediately report the loss of my ECHS Membership Card to Station HQs. Signature of Deponent V ERIFICATION I, the deponent above named, do hereby solemnly declare and verify that the contents of the above affidavit are true to the best of my knowledge and belief, and nothing material has been concealed or suppressed therefrom. Verified at (Place)………… on this (Date) ………….. day of (Month)………. (Year) …………. Signature of Deponent ATTESTATION Certified that the above statement is declared before me at (Place) ………. on this ………….. day of (Month)……… (Year) ……… by DEPONENT Service No …………Rank ….... Name …………………… who is identified by Name …………………… S/O (Father’s name of Identifier) ………………….. and witnessed by Name ……………………S/O (Father’s name of first witness) & Name ………………………. S/O (Father’s name of second witness). Identified by Signature of Identifier (Name in Block Capitals) (Full Postal Address) WITNESS Signature of Witness No 1 1. (Name in Block Capitals) (Full Postal Address) Signature of Witness No 2 2. (Name in Block Capitals) (Full Postal Address) ATTESTED BY MAGISTRATE/NOTARY PUBLIC Application Regn No_______________________ RECEIPT FOR DOCUMENTS EX SERVICEMEN CONTRIBUTORY HEALTH SCHEME (ECHS) (TO BE PRODUCED BY EX -SERVICEMAN AT THE TIME OF COLLECTION OF MEMBERSHIP CARD) Received following documents from No____________ Rank_________ Name ____________________ towards application for membership of Ex-Servicemen Contributory Health Scheme (ECHS):- 1. Application form (duly completed) 2. Photograph of Pension er and each dependant(s) 3. Affidavit in original (duly attested) 4. Copy of MRO (duly receipted) 5. Photocopy of PPO 6. Photocopy of Discharge book (except Naval Officers) 7. Photocopy of ESM Identity Card. Place: Date: (Signature of Officer ) (Adm Comdt/SSO/Officer Station Headquarters) INSTRUCTIONS FOR EX-SERVICEMEN HOW TO BECOME AN ECHS MEMBER 1. Eligibility. Only Ex-Servicemen drawing pension/disability pension or widows who are in receipt of family pension ar e eligible to apply. He/she may approach nearest Station HQs/Military Hospitals at 104 Military Stations and collect the application form for enrolment into the ECHS scheme. The application form will also be made available through CSDs, Army/Navy/AF Hospitals, and Rajya/Zila Sainik Boards. ECHS also covers dependants – see conditions stipulated in application form. 2. Please check the following pages when collecting the application form :- (a) Receipt for handing over of document & instructions for filling up form. (b) Application Form - comprises 3 pages (1 page for pasting photograph). (c) Affidavit format (one page). (d) Four copies of MRO and amount to be deposited as per pension drawn. COMPLETION OF DOCUMENTATION 3. Fill in the application form as per de tails required. While filling, care must be taken that name(s) of dependant(s) tally with service documents / records. All columns and necessary details must be filled; otherwise the application will be rejected. 4. An affidavit as per format, duly attested by a Magistrate / Notary Public, will be submitted. 5. Deposit an MRO as per the contributing amount based on the Basic pension (excluding DA). 6. Prepare one photocopy each of PPO, Discharge book and ESM identity card. DEPOSITING APPLICATION FORMS /DOCUMENTS AT DESIGNATED LOCATIONS 7. Attach the original copies and a photocopy each of your PPO, Discharge book and ESM verified Identity card with your Application Form. Deposit the Application Form and documents with a Regional Centre, Station HQ or Army/Navy/AF Hospital. They will initially scrutinise your papers, and also help you if you have left out any essential details. Before leaving, ensure that the Receiving Officer/JCO/Clerk enters your particulars & date of receipt of application in his temporary register. Your Application Form & all documents will thereafter be sent to a designated Station HQ for detailed scrutiny. At Station HQs, the Adm Comdt/SSO will attest photocopies of essential documents after comparing with originals. Photocopies will be retained. 8. After 5-6 days, a Receipt bearing an Application Registration No, and your original documents will be returned to you. You may collect these, either directly from the Station HQs or from the place where you originally submitted your Application. Please ensure that originals are received intact. Retain your Receipt carefully as you will be required to produce this when collecting your ECHS Membership Card. In case of any query/delay you must quote this Registration number to Station HQs. COLLECTING ECHS MEMBERSHIP CARD & AVAILING TREATMENT 9. Report to Station HQs with your receipt not earlier than 30 days, but also not later than 45 days from date of initial submission of Application, and collect your ECHS Membership Card. You will have to personally sign at the Station HQs a token of having received your Card. TO AVAIL MEDICAL TREATMENT AT ANY POLYCLINIC / EMPANELLED HOSPITAL, IT IS MANDATORY FOR PENSIONERS/WIDOWS TO FIRST REPORT TO NEAREST POLYCLINIC ALONG WITH ECHS MEMBERSHIP CARD.
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