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Life Certificate Format 2024-25

The document is a life certificate form that collects personal details and dependent information from retired BPCL employees to continue receiving retirement benefits. It collects name, address, contact details, and lists current dependents. Beneficiaries of the post-retirement medical benefit scheme must confirm their dependents. VRS optees must declare if they meet eligibility criteria. Widows/widowers must declare their marital status and that they are not receiving benefits elsewhere to continue receiving benefits from applicable schemes.

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2K views1 page

Life Certificate Format 2024-25

The document is a life certificate form that collects personal details and dependent information from retired BPCL employees to continue receiving retirement benefits. It collects name, address, contact details, and lists current dependents. Beneficiaries of the post-retirement medical benefit scheme must confirm their dependents. VRS optees must declare if they meet eligibility criteria. Widows/widowers must declare their marital status and that they are not receiving benefits elsewhere to continue receiving benefits from applicable schemes.

Uploaded by

svkadam5949
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PHOTO OF

PHOTO OF SPOUSE
LIFE CERTIFICATE FOR FOR
LIFE CERTIFICATE 20242023-2024
- 2025 SELF (Wherever
applicable)

1. TO BE FILLED BY ALL

I, ______________________________________________ Staff No.________________, Medical Ref. No./ Vendor No. (8 digit


number) _____________________ OR I, _____________________________________Spouse of Ex-staff (Name & Staff No.)
___________________________________________________ Retired/Separated from the services of BPCL/ Burmah shell/KRL
on _________________ and I am availing Retirement Benefits of the Corporation.

❖ Declaration for Personal Details:


I declare that the above furnished information is true and correct and my current details are as under:

Address: ___________________________________________________________________________________________
Contact No. / Mobile: ______________________________ Email ID: __________________________________________

2. TO BE FILLED BY MEMBER OF POST RETIREMENT MEDICAL BENEFIT SCHEME (PRMBS)

Declaration for confirmation of beneficiaries under PRMB Scheme


I hereby declare that the following members are my dependents as per the PRMB Scheme and request you to continue their benefits. I agree that
the medical benefits under PRMBS is being extended to my beneficiaries solely based on the aforesaid undertaking

NAME OF BENEFICIARY RELATIONSHIP GENDER (M/F) DATE OF BIRTH OCCUPATION

3. TO BE DECLARED BY VRS OPTEES UNDER BPVRS2020 ONLY (please tick, if applicable)

Declaration for availing medical benefits under Post-Retirement Medical Benefit Scheme.
I hereby confirm that my age is less than 60 years & I am not gainfully employed. I agree that the medical benefits under PRMBS is being extended
to me solely based on the aforesaid undertaking. If I take up any gainful employment, I shall inform the Corporation within 30 days.

4. TO BE DECLARED BY WIDOW / WIDOWER OF EX-STAFF (please tick on the schemes, as applicable)

o Post-Retirement Medical Benefit Scheme (PRMBS)


o Burmah Shell Pension Scheme
o Death-in-Service Scheme
I hereby declare that there has been no change in my marital status since demise my spouse who was ex-employee of the Corporation and I am not
availing medical benefits from anywhere else other than BPCL. I agree that the benefits under the schemes mentioned above are being extended to me
solely based on the aforesaid undertaking.

Signature: ______________________ Date: __________________________

CERTIFICATE

Certified that I have seen Shri/Smt. __________________________________________________, who has signed


above and has been known to me for _________ years and that he/she is alive on this date.
Name of Attesting Officer : ______________________
SEAL
Designation of Attesting Office : ______________________
Signature of Attesting Officer : ______________________
Contact No. / Mobile : ______________________
NOTE:
i Attestation can be done by Management Staff in service of BPCL OR Gazetted Officer OR Bank Manager OR Registered Medical Practitioner
OR Village Officer OR Panchayat Officer OR Magistrate OR Police Officer OR Notary Public
ii This Life Certificate is applicable for BPCL benefits only. For EPF & LIC / SBI Life / HDFC Life / ICICI Pension, etc. separate Life Certificate
as applicable may be sent to concerned authorities.
iii The filled copy of Life Certificate to be sent to the following address latest by 15 March 2024 to CENTRALISED BENEFIT ADMIN (CBA),
BHARAT PETROLEUM CORPORATION LIMITED (BPCL) SOUTHERN REGIONAL OFFICE (SRO)1, RANGANATHAN GARDENS
OFF.11TH MAIN ROAD, ANNA NAGAR WEST, CHENNAI – 600 040. Ph 044-26142021 / 6382264412

BPLC2324 For any query pertaining to Life Certificate Submission you may also write to: z_centralcell_hr@bharatpetroleum.in

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