187[Notwithstanding anything contained in these regulations, wherever, on-line system of functioning has been introduced, the registration of factory/establishment and employees, filing of contributions, generation of challans, payment of contributions, submission and processing of claims for benefits and all other related procedures under the Act and the rules and regulations made thereunder, shall be submitted/made on-line, with necessary digital signatures, wherever required, under these regulations, as may be specified by the Director General from time to time.]
188[189[Form 01
| 1. |
Name of the Unit (Factory/Establishment): |
| Full address along with Pin |
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Jurisdictional |
| Code No. Municipality Ward No. (if in a Rev. Village, Name of the Village, Hobli and all other details of demarcation) |
Phones Nos./Mobile No. and e-mail address, Fax No. |
Police Station |
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| 2. |
Exact nature of activity |
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(work/business carried on) |
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| 3. |
Date of commencement of the Unit |
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| 4. |
(a) Whether the |
(i) |
Building/premises of the unit are hired/owned/leased. |
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(ii) |
Machinery and Fixtures of the unit are hired/owned/leased. |
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(b) Date of purchase/lease. |
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| 5. |
Please indicate: |
(a) |
Reg. No. issued by concerned regulatory authority (Factory/Establishment/Shop/Educational and Medical Institutions) |
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(b) |
PF Registration No. |
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(c) |
Income Tax/Service Tax/PAN/GIR No. |
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(d) |
Bank Account No./Name and Branch of the Bank |
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First date on which 10/20 or more persons were employed (including persons employed through immediate employers) |
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| 7. |
Nature of management (Proprietorship/Partnership/Public Limited Co.,/Pvt. Ltd. Co./Co-op. Society etc.) |
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| 8. |
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| Name and addresses of the present principal employers (i.e., Proprietor/Partners/Managing/Executive Directors/Chairman/Secretary and the Manager of the Unit.) |
Names and Desig-nations |
Permanent Address |
Telephone Nos. including mobile numbers and e-mail address |
| 9. |
Addresses of Registered Offices/Head Office/Branch Office/Sales Offices/Administrative Offices and No. of employees employed therein. |
| Full Addresses |
No. of employees employed |
Tel. Nos. |
| 10. |
Total No. of persons employed and No. of Employees whose wages does not exceed Rs 15000 P.M. |
: |
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(i) |
By principal employer |
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(ii) |
Through Immediate Employer (Without ESI Code No.) |
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(iii) |
Through Immediate Employer (Having ESI Code No.) |
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As on .. |
| Signature of the Principal Employer (along with date) |
| DECLARATION |
| I have read the instructions and hereby declare that all the particulars given above are true and correct to the best of my knowledge and belief. In case of any change at any time in the information given above, I undertake to intimate those changes, to the RO/SRO/Branch Office within 15 days. |
| Place: |
| Date: |
| Signature of the Principal Employer (Along with date) |
| INSTRUCTIONS |
| 1. |
The regional office and the concerned branch office of the corporation shall be informed within 7 days with valid copies of the related documents in cases of any change in |
| |
(i) |
The address of the location of work, administration office, branch office, sales office etc. |
| (b) |
The change of management like Proprietorship to Partnership etc. |
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(i) |
Any change in the existing incumbents along with list of new incumbents and their permanent addresses and phone numbers. |
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(ii) |
Transfer of the unit by sale/gift/lease etc., along with the copies of connected documents. |
| (c) |
Any change in/addition to the existing activities, closure of/creation of new sales offices/branch office etc. |
| 2. |
In case of permanent closure, the same shall be duly intimated along with copies of the connected documents to the Regional Office and the concerned branch office immediately and the returns shall be submitted in accordance with Regulation 26(b) of ESI (General) Regulations, 1950.] |
Form 01(A)
Form of Annual Information of Factory/Establishment covered under ESI Act
(See Regulation 10-C)
| 1. |
Name of the factory/establishment |
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| 2. |
Complete postal address of the Factory/Establishment |
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| 3. |
(a) Telephone No., if any |
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(b) Fax No., if any . . . . . .. . . . . . . . . . . . . . |
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(c) E-mail address, if any . . . . . . . . . |
| 4. |
Location of factory/establishment |
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(a) State . . . . . . . . . . . . . . . . . . . . . . |
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(b) District . . . . . . . . . . . . . . . . . . . . . |
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(c) Municipality/Ward. . . . . . . . . . . . |
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(d) Name of Town/Revenue Village (Taluk/Tahsil) . . . . . . . . . . . . . . . |
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(e) Police Station . . . . . . . . . . . . . . . . |
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(f) Revenue Demarcation/Hudbast No. . . . . |
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(a) Details of Bank A/c: |
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(b) Name of Bank and Branch |
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(a) Account No. . . . . . . . . . . . . |
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(i) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
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(b) Account No. . . . . . . . . . . . . |
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(ii) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
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(c) Account No. . . . . . . . . . . . . |
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(iii) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| 6. |
(a) Income Tax PAN/GIR No. |
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(b) Income Tax Ward/Circle/Area |
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| 7. |
(a) In case of factory whether licence issued under Section 2(m)(i) or 2(m)(ii) of the Factories Act, 1948 |
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(b) Power Connection No. |
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No. Sanctioned power load Issuing Authority |
| 8. |
(a) Whether it is Public or Private Ltd. Company/Partnership/Proprietorship/Cooperative Society/Ownership (Attach copy of Memorandum and Articles of Association/Partnership Deed/Resolution) |
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(b) Give name, present and permanent residential address of present Proprietor/Managing Directors, Director/Managing Partners, Partners/Secretary of the Co-operative Society |
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NameDesignationAddress (i) (ii) (iii) (iv) (v) (vi) (vii) |
| 9. |
Address(es) of the Registered Office/Head Office/Branch Office/Sales Office/Administrative Office/other offices, if any, with number of employees attached with each such office and person responsible for the office |
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Address as on date |
No. of employees |
Phone No./Fax No. |
Function |
Person responsi-ble for day-to-day functio-ning of the office |
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(Give details on a separate sheet, if required) |
| 10. |
(a) Whether any work/business carried out through contractor/immediate employer |
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(b) If yes, give nature of such work/business |
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| I hereby declare that the statement given above is correct to the best of my knowledge and belief. I also undertake to intimate changes, if any, promptly to the Regional Office/Sub-Regional Office, ESI Corporation as soon as such changes take place. |
| Date |
Name and Signature . . . . . . . . . . . . . . |
| Place |
Designation with seal . . . . . . . . . . . . . |
[Should be signed by principal employer under Section 2(17) of ESI Act]]
190[Form I
Declaration Form
(To be submitted in respect of employee who is not already registered under ESI Act)
1.
| Name of the Employee (In Block Letters) |
Date of Birth/Age |
Sex |
Marital Status |
| |
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|
M |
F |
M |
U |
W |
2.
| Full Residential Address including Pin Code No. Phone/Mobile No. and E-mail Address |
Present |
Permanent |
Bank Details |
| |
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Name of Bank, Branch and A/c No. |
| 3. |
Father's/Husband's Name : . |
| 4. |
Date of appointment: |
ESI Dispensary |
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Chosen for Treatment |
| 5. |
Name and Address of the Employer and the Branch Office to which attached (Affix the Seal): |
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| 6. |
Details of the Nominee for payment of Cash Benefits after death: |
| Name |
Relationship and age of the nominee |
Permanent Address |
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7. Family Particulars:
| Sl. No. |
Name and Relationship with the I.P. |
Date of Birth and Age as on date |
Whether residing with the I.P. |
If residing elsewhere, address along with name of the State |
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| (In case the insured person is unmarried and his/her parents are not alive, details of minor brother or sister of the insured person wholly dependent on him may be given) |
| 8. |
Please indicate total monthly income of dependent parents, if any, from all sources: |
| 9. |
In case of person with disability, please specify the nature of disability and its percentage (Please enclose relevant documents). |
| DECLARATION |
| 1. |
I undertake to intimate any change in the membership of my family within 15 days of such change. |
| 2. |
I hereby certify that particulars furnished above are true to the best of my knowledge. Signature of the I.P. |
| Countersignature of Principal Employeror Authorised Signatory (along with name and date)] |
|
Form I-A
Family Declaration Form
(Regulation 15-A)
Name of the insured person. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Insurance Number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
| Serial No. |
Name |
Date of Birth |
Relationship with insured persons |
Whether residing with him/her or not |
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I hereby declare that the particulars above have been given by me and are true to the best of my knowledge and belief. I also undertake to intimate to the Corporation any changes in the membership of my family within 15 days of such changes having occurred.
Date. . . . . . .
Signature or thumb impression of the insured person
Countersigned. . . . . . .
Date .. . . . . . . . . . . .
Designation. . . . . . . . .
Name, address and Code No. of Employer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
191[Note. According to Section 2, clause (11) of the Employees' State Insurance Act, 1948, family means all or any of the following relatives of an insured person, namely, (i) a spouse; (ii) a minor legitimate or adopted child dependant upon the IP; (iii) a child who is wholly dependant on the earnings of the IP and who is (a) receiving education, till he or she attains the age of 21 years, (b) an unmarried daughter, (iv) a child who is infirm by reason of any physical or mental abnormality or injury and is wholly dependant on the earning of the IP, so long as the infirmity continues; (v) dependant parents.]
192[Reg. Form 2
Addition/Deletion in Family Declaration Form Employees' State Insurance Corporation
(Regulation 15-B)
Name of the insured person. . . . . . . . . . . . . . . . . . . . . . . . .Insurance No.
I declare that the person/persons whose particulars are given below has/have now become/ceased to be member(s) of my family.*
| Sl. No. |
Name |
Date of Birth |
Reason(s) for change and date |
Relationship with the Insured Person |
Whether residing with him/her or not, state |
If no, where residing |
Name of IMP/Disp. attached |
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Yes |
No |
Distt. |
State |
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I hereby declare that the particulars given above are true to the best of my knowledge and belief.
Necessary changes may kindly be made in my Declaration Form submitted earlier.
Passport size photographs of the members who are added to family is/are enclosed.
| Place . . . . . . . . . . . . . . . . . |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| Date . . . . . . . . . . . . . . . . . |
Signature/thumb impression of the employees |
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Name in Block Letters . . . . . . . . . . . . . . . . . . |
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Particulars of the Employer |
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Name: . . . . . . . . . . . . . . . . . . |
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Address . . . . . . . . . . . . . . . . . |
Counter-signature of the employer |
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. . . . . . . . . . . . . . . . . . . . . . . . |
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Code No. . . . . . . . . . . . . . . . . |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
|
Designation with Rubber Stamp |
Note. Family means all or any of the following relatives of an Insured Person, namely:
(i) a spouse; (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a child who is wholly dependant on the earnings of the I.P. and who is (a) receiving education, till he or she attains the age of 21 years (b) and unmarried daughter; (iv) a child who is infirm by reason of any physical or mental abnormally or injury and is wholly dependant on the earnings of the I.P. so long as the infirmity continues; (v) dependant parents (Please see Section 2 Clause 11 of the ESI Act, 1948 for details).
* Please submit duly attested copy of the Birth/Death Certificate.]
Form 3
(Regulation 14)
Return of Declaration Forms
Name and address of the
Factory or Establishment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Employer's Code Number
I send herewith the Declaration Forms in respect of the employees mentioned below. I hereby declare that every person employed as an employee within the meaning of Section 2(9) of the Employees' State Insurance Act, 1948, on . . . . . . . . in this factory or establishment and in receipt of a remuneration not exceeding 193[Rs 10,000] per month has been included in this list (excepting only those in respect of whom declarations have been sent to the Corporation in the past).
Place . . . . . . . . . . . .Signature. . . . . . . . . . . . .
Date . . . . . . . . . . . .Designation. . . . . . . . . . .
| Serial No. |
Name of the employee |
Distinguishing No. with the employer if any |
Father's or Husband's name |
Insurance No. allotted by the Corporation (to be entered in the Appropriate Office) |
| (1) |
(2) |
(3) |
(4) |
(5) |
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Signature. . . . . . . . .
Designation. . . . . . .
Enclosures:
Declaration Forms . . . . . . . . . .
Continuation sheets . . . . . . . . . .
Form 4
Identity Card
(Regulation 17)
Insurance No.
| Name . . . . . . . . . . . . . . Sex . . . . . . . . . . . . . . . . . S/o d/o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . w/o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Year of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dispensary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Local office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
Identification marks Photograph of the insured person Employment changes |
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Date |
Code No. |
Date |
Code No. |
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| Prepared by |
Signature of thumbimpression of the employee. |
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Form 4-A
Family Identity Card
(Regulation 95-A)
Insurance No.
Name of insured person. . . . . . . . . . . . . .
Sex. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Son of/Daughter of/Wife of. . . . . . . . . . . .
Address. . . . . . . . . . . . . . . . . . . . . . . . .
Dispensary. . . . . . . . . . . . . . . . . . . . . . . .
Particulars of members of family
| Serial No. |
Name |
Date of birth |
Relationship with the insured person |
Identification Marks |
| 1 2 3 4 5 6 |
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Signature or thumb-impression of theinsured person
Prepared by
Signature of Inspector orAuthorised Official
194[Reg. Form 5
* Due Date for submission:
Name of Branch Office Employer's Code No. .
RETURN OF CONTRIBUTIONS
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 26)
| Name and address of the factory or establishment |
: |
. |
| Particulars of the Principal employer(s) |
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| (d) Name |
: |
. |
| (e) Designation |
: |
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| (f) Residential Address |
: |
. |
Contribution Period from to
I furnish below the details of the Employer's and Employee's share of contributions in respect of the under mentioned insured persons. I hereby declare that the return includes each and every employee, employed directly or through an immediate employer or in connection with the work of the factory/establishment or any work connected with the administration of the factory/establishment or purchase of raw materials, sale or distribution of finished products etc. to whom the ESI Act, 1948 applies, in the contribution period to which this return relates and that the contributions in respect of employer's and employee's share have been correctly paid in accordance with the provisions of the Act and regulations.
Employee's Share ..
Employer's Share ..
Total Contribution .
Details of Challans:
| Sl. No. |
Month |
Date of Challan |
Amount |
Name of the Bank and Branch |
| 1. |
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Total amount paid Rs
I declare that
(w) All the Records and Registers have been maintained as per provisions contained in ESI Act, rules and regulations framed therein.
(x) During the period of return No. of Declaration forms have been submitted.
(y) During the above period No. of TICs have been received.
(z) During the above period No. of PICs have been received.
(aa) During the above period No. of PICs have been distributed amongst the eligible IPs.
(bb) During the above period accidents have been reported to the concerned Branch Office.
(cc) During the period . No. of employees directly employed by us have been covered and a total wages of Rs .. have been paid to such employees.
(dd) During the period .. No. of employees directly employed by us have not been covered and a total wages of Rs have been paid to such employees.
(ee) During the period .. No. of employees employed through immediate employer have been covered and a total wages of Rs have been paid to such employees.
(ff) During the period No. of employees employed through immediate employer have not been covered and a total wages of Rs .. have been paid to such employees.
(gg) Following components of wages have been taken into consideration for the purpose of payment of contribution
1.
2.
3.
4.
5.
(j) Following components of wages have not been taken into consideration for the purpose of payment of contribution
1.
2.
3.
4.
5.
The abovementioned information is based on records and any information if found incorrect will render me liable for prosecutions under provisions of ESI Act and action for recovery of contribution due along with interest and damages as per provisions of the ESI Act.
| Place |
Signature and Designation of the Employer |
| Date |
(with Rubber Stamp) |
CERTIFICATE BY CHARTERED ACCOUNTANT
(To be submitted in case of employers employing 40 or more employees)
Certified that I have verified the above return from the Records and Registers of M/s. . . and found it to be correct.
Signature and Seal
of the Chartered Accountant with
Membership No.
Important instructions: Information to be given in Remarks Column (No. 9)
(vii) If any I.P. is appointed for the first time and/or leaves during the contribution period indicate A (date) and/or L . (date) .
(viii) Please indicate Insurance Nos. in ascending order.
(ix) Figures in Columns 4, 5 and 6 shall be in respect of wage periods ended during the contribution period.
(x) Invariably strike totals of Columns 4, 5 and 6 of the Return.
(xi) No overwriting shall be made. Any corrections, if made, should be signed by the employer.
(xii) Every page of this Return should bear full signature and rubber stamp of the employer.
(xiii) Daily wages in Column 7 of the return shall be calculated by dividing figures in Column 5 by figures in Column 4 to two decimal places.
For *CP ending 31st March, due date is 12th May
For CP ending 30th September, due date is 11th November
EMPLOYEES' STATE INSURANCE CORPORATION
Employer's Name and Address
Employer's Code No Period from to .
| Sl. No. |
Insurance Number |
Name of Insured |
Person No. of days for which wages paid |
Total amount of wages paid (Rs) |
Employee's contribution deducted (Rs) |
Average Daily Wages (Rs) |
Whether still continues working |
Re-marks* |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
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TOTAL |
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*Date of appointment and leaving the job may be given in remarks columnSignature of the Employer
(FOR OFFICIAL USE)
4. Entitlement position marked.
5. Total of Column 5 of Return checked and found correct/correct amount is indicated.
6. Checked the amount of Employer's/Employee's contribution paid which is in order/observation memo enclosed.
Countersignature ..
| U.D.C. |
Head Clerk |
Branch Officer] |
195[Form 5-A
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 31 Second Proviso)
Statement of Advance Payment of Contributions made for the Contribution Period ended . . . . . . . . . . . . .
Total contribution amounting to Rs . . . . . . . . . . . . . . . . . . . . . . comprising of . . . . . . . . . . . . . . . . . Rs . . . . . . . . . . . . . . . as employer's share and Rs . . . . . . . . . . . . . . as employees' share paid as under:
| Sl. No. |
Details of Advance Payment |
Amount |
Details of actual contribution paid |
Amount |
Balance |
| 1 |
2 |
3 |
4 |
5 |
6 |
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Rs.P. |
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| 1. |
Opening Balance |
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| 2. |
Challan dated . . . . |
. . . . . . . . . . . |
*April/October |
. . . . . . . . . . |
. . . . . . . . . . |
| 3. |
Challan dated . . . . |
. . . . . . . . . . . |
*May/November |
. . . . . . . . . . |
. . . . . . . . . . |
| 4. |
Challan dated . . . . |
. . . . . . . . . . . |
*June/December |
. . . . . . . . . . |
. . . . . . . . . . |
| 5. |
Challan dated . . . . |
. . . . . . . . . . . |
*July/January |
. . . . . . . . . . |
. . . . . . . . . . |
| 6. |
Challan dated . . . . |
. . . . . . . . . . . |
*August/February |
. . . . . . . . . . |
. . . . . . . . . . |
| 7. |
Challan dated . . . . |
. . . . . . . . . . . |
*September/March |
. . . . . . . . . . |
. . . . . . . . . . |
| |
Total (i) |
. . . . . . . . . . . |
Total (ii) Total due for contribution period Total amount paid in Advance Balance |
|
|
| Total (ii) should not be less than total (i) at any time *Strike out which is not applicable |
|
|
| Place . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . |
Signature . . . . . . . . . . . . . . . . . . Designation . . . . . . . . . . . . . . . .] |
196[Reg. Form 6
Register of Employees
EMPLOYEES STATE INSURANCE CORPORATION
(Regulation 32)
Contribution period : From . . . . . . . . . . . . to . . . . . . . . . . .Month . . . . . . . . . . . . . . . .
| Sl. No. |
Insurance number |
Name of the insured person |
*Name of dispensary to which attached |
Occupation |
Deptt. and shift, if any |
If appointed or left service during the contribution period, date of appointment/leaving service |
No. of days for which wages paid/payable |
Total amount of wages paid/payable |
Employee's share of contribution |
| 1 |
2 |
3 |
3-A |
4 |
5 |
6 |
7 |
8 |
9 |
| |
|
|
|
|
|
|
|
|
|
| Total Employers' share Grant total Paid on |
Month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
| No. of days for which wages paid/payable |
Total amount of wages paid/payable (Rs) |
Employees' share of contribution (Rs) |
No. of days for which wages paid/payable |
Total amount of wages paid/payable (Rs) |
Employees' share of contribution (Rs) |
| 10 |
11 |
12 |
13 |
14 |
15 |
| Total Employers' share Grant total Paid on |
Month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
| No. of days for which wages paid/payable |
Total amount of wages paid/payable (Rs) |
Employees' share of contribution (Rs) |
No. of days for which wages paid/payable |
Total amount of wages paid/payable (Rs) |
Employees' share of contribution (Rs) |
| 16 |
17 |
18 |
19 |
20 |
21 |
| Total |
| Employers' share |
| Grant total |
| Paid on |
Month
| No. of days for which wages paid/payable |
Total amount of wages paid/payable (Rs) |
Employees' share of contribu-tion (Rs) |
Total No. of days for which wages paid/payable in Contribution period |
Total amount of wages paid/payable in the contribution period (Rs) |
Total Employees' share of Contribution in contribution period (Rs) |
Daily wage (25-26 |
| 22 |
23 |
24 |
25 |
26 |
27 |
28 |
| Total |
| Employer's share |
| Grant Total |
| Paid on |
Note. The figures in Columns 7 to 24 shall be in respect of wage periods ending in a particular calendar month.]
197[Reg. Form 7
(Confidential)
(Deposit this certificate within 3 days with the appropriate Branch Office to avoid possible loss of benefit under Regulation 64)
First Intermediate/Final Certificate
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulations 57, 58, 59 198[and 89-B])
| Book No. . . . . . . . . . . . . . |
|
. . . . . . . . . .. . . . . . . . . . . . . . . . . . . |
| Serial No. . . . . . . . . . . . . . . |
Stamp of the dispensary |
Signature or Thumb impression of the I.P. |
| Date of First Certificate of spell of Sickness or |
Employer's Code No. . . . . . . . |
| Disablement . . . . . . . . . . . . . . . . . . .. . . . . . . . |
Branch Office . . .. . . . . . . . . . . . . |
| Name . . . . . . . . . . . . . . . . . . . . . . . s/w/d of. . . . . . . . . . . . . . . . . . . . . Ins. No. . . . . . . . . . . . . . . . . . . . . . |
Certified that I have examined you today and that in my opinion:
| Any other remarks by the Medical Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attested by Medical Officer |
(i)* You now need medical treatment, attendance and abstention from work on medical grounds by reason of (diagnosis) . . . . (ii)* You have continued to need medical treatment, attendance and abstention from work on medical grounds up to and including this day by reason of (diagnosis) . . . . . . . . . . . . . . (iii)* In my opinion you will be fit to resume work tomorrow/on . . . . . . . . . . . . . . . . . . . |
Note. The date of fitness must in no case be later than the third day after the date of the examination in case of First and Final Certificate
| Date . . . . . . . . . . . . . . . . . . |
Signature . . . . . . . . . . . . |
|
| |
Insurance Medical Officer |
Rubber stamp |
Name in Block Letters . . . . . . . . . . . . . . . . . . .
* Strike out whichever is not applicable
Important:
1. Any person who makes false statement or representation for the purpose of obtaining benefit whether for himself/some other person shall be punishable with imprisonment up to 6 months or fine up to Rs 2000 or both.
2. This form should be completed and submitted without delay to the appropriate Branch Office to escape penal deduction of benefit under Regulation 64 read with Regulation 99 of ESI (General) Regulation, 1950.
3. Insured person must sign, with date, the claim form to avoid delay and inconvenience.]
199[Reg. Form 8
(Confidential)
(Deposit this certificate within 3 days with the appropriate Branch Office to avoid possible loss of benefit under Regulation 64)
Special Intermediate Certificate
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulations 61 and 8-B)
| Book No. . . . . . . . . . . . . . |
|
. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . |
| Serial No. . . . . . . . . . . . . . . |
Stamp of the dispensary |
Signature for Thumb impression of the I.P. |
| Date of First Certificate of spell of Sickness or |
Employer's Code No. . . . . . . . . . . |
| Disablement . . . . . . . . . . . . . . . . . . .. . . . . . . . |
Branch Office . . . . . . . . . . . . . |
| To . . . . . . . . . . . . . . . . . . . . . . . . s/w/d of. . . . . . . . . . . . . . . . . . . . . . Ins. No. . . . . . . . . . . . . . . . . . . . . . |
| Any other remarks by the Medical Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attestation by Medical Officer |
Certified that I have examined you . . . . . . . . . . . . . . . . . . . . today and that in my opinion you have continued to need medical treatment and have remained incapable to work up to and including this day by reason of . . . . . . . . . . . . . .. . . . . . . I further certify that by judging your present condition it is found that your sickness is of such a character that it will be unnecessary to see you for the purpose of treatment more frequently than once in . . . . . . . . . . . . . . weeks, and you will required medical treatment and will remain incapable to work at least up to the end of . . . . . . . . . . . . . . weeks from this date . . . . . . . . . . . . I propose to issue certificates in this form at the interval stated above, so long as your condition does not require more frequent attendance. In my opinion you should now/need not be referred to a Medical Board to determine if you are permanently disabled |
| Date . . . . . . . . . . . .. . . |
Signature . . . . . . . . . . . . |
|
| |
Insurance Medical Officer with rubber stamp |
Name in Block Letters] |
200[Reg. Form 9
Claim for Sickness/T.D.B./Maternity benefit for Sickness
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulations 63 and 89-B)
I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .s/w/d of . . . . . . . . . . . . Insurance No. . . . . . . . . . . . . . . . . . . . . . . . . hereby claim Cash Benefit for period overleaf and state.
(i)* That because of sickness/temporary disablement/sickness due to pregnancy/confinement/premature birth of child/miscarriage, I have not been at work since . . . . . . . . . . . . . . . . . . .
(ii)* I no longer claim to be sick/temporary disabled/sick due to pregnancy/confinement/premature birth of child/miscarriage from . . . . . . . . . . . . . . . and I shall/did not take up any work for remuneration before that date.
(iii)* I have not been in receipt of any wages for the days of leave/holiday(s).
(iv)* I was not on strike during the period of certified abstention on account of sickness/temporary disablement i.e. from . . . . . . . . . . . . . to . . . . . . . . . . . . . for which the benefit is claimed.
I desire payment in *cash at Branch Office/By Money Order.
Signature or T.I. of Claimant
Name in Block Letters . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Notes:
1. Any person who makes false statement or representation for the purpose of obtaining benefit whether for himself/some other person shall be punishable with imprisonment up to 6 months or fine up to Rs 2000 or both.
2. This form should be completed and submitted without delay to the appropriate Branch Office.
3. A final certificate must be obtained before resuming work.
* Strike out if not applicable.]
201[Reg. Form 10
(confidential)
Abstention Verification in respect of Sickness Benefit/Temporary Disablement Benefit/Maternity Benefit
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 52-A)
From:
The Manager
. . . . . . . . . . . . Branch Office,
E.S.I. Corporation.
To,
M/s . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .. . . . . . . . . .
Subject: Verification of abstention from work in respect of Shri/Smt/Km . . . . . . . . . . . . . . . . . . . .
Ins. No. . . . . . . . . . . . . . . . . . . . . . . . Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dear Sir(s)
The above named employee of your factory has submitted a certificate of incapacity for the period from . . . . . . . . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . . . and has declared that he/she has not worked on any day during the above period.
He/She has further declared that he/she has not received wages as defined under Section 2(22) of ESI Act, 1948 for any leave/holiday/weekly off/lay off and strike in respect of any day during the above period and that he/she was not on strike on any day during the above period.
I shall be grateful if you confirm the exact position, in this regard, on the form, appended within 10 days of the receipt of this form.
Yours faithfully
Manager
. . . . . . . . . . . . . . Branch Office
CONFIDENTIAL
REPLY TO BE FURNISHED BY THE EMPLOYER IN RESPECT OF FORM NO. 10
Name of the Insured Person/Insured Woman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Insurance No. . . . . . . . . . . . . . . . . . . . . . . . .
Returned with the remarks that the employee in question has not worked on any day during the period from . . . . . . . . . . . . . . . . . . to . . . . . . .. . . . . . . . . . . . or* that he/she has worked on . . . . . . . . . . . . . . . . . . . during the period from . . . . . . . . . . . . . . to . . . . . . . . . . .
It is further confirmed that
(a) He/She remained on leave with wages for the period from . . . . . . . . . . . . to . . . . . . . . . . . .
(b) He/She remained on holidays with wages from . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . . . . .
(c) He/She was on weekly off with wages from . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . . . . .
(d) He/She was on lay-off with wages from . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . . . . . . . . .
(e) He/She was on strike from . . . . . . . . . . . . . . . . . to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. In case, the IP/IW is paid any wages for any of the days falling during the abovementioned period subsequently, the same will be notified to you in due course.
3. The day proceeding the first day of absence was*/was not a holiday for the Insured Person/Insured Woman.
| |
Signature . . . . . . . . . . . . . . . . . |
| Date . . . . . . . . . . . . . . . . . . |
Name in block letter and designation . . . . . . . . . . |
| |
Code No. . . . . . . . . . . . . . .] |
| * Strike out if not applicable |
|
202[Reg. Form 11
Accident Book
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 66)
| Sl. No. |
Date of Notice |
Time of Notice |
Name and Address of Injured Person |
Sex |
Age |
Insurance No. |
Shift, department and Occupation of the employee |
Details of Injury |
| Cause |
Nature |
Date |
Time |
Place |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
| |
|
|
|
|
|
|
|
|
|
|
|
|
| What exactly was the injured person doing at the time of accident |
Name, occupation, address and signature or the thumb impression of the person(s) giving notice |
Signature and designation of the person who makes the entry in the Accident book |
Name, address and occupation of two witnesses |
Remarks, if any |
| 14 |
15 |
16 |
17 |
18 |
| |
|
|
|
|
203[Form 12
Accident Report from Employer under Regulation 68
| |
Date of Accident: |
| 1. |
Name, Insurance No. of injured person |
| 2. |
Department and Shift Hours |
| 3. |
Was he/she an employee under the Act on the day accident |
| 4. |
Exact time and place of accident |
| 5. |
Nature and Location of injury (Give accurate details) |
| 6. |
Extent of injury (Simple, Grievous involving fracture(s). Likely to result in permanent disability, fatal) Hospitalised/Not Hospitalised as in-Patient |
| 7. |
Whether the accident reported to the Inspector of Factories (Yes/No) |
| 8. |
If accident occurred outside the premises of the factory or establishment |
| |
(A) |
Exact spot of the accident |
| |
(B) |
Where he was travelling to at that time |
| |
(C) |
The details of the vehicle he was travelling at the time of accident, registration no., make, whether it is his own etc. |
| |
(D) |
Whether he was on official duty or coming to work place or returning home |
| |
(E) |
Is F.I.R. lodged and any postmortem conducted |
| Date of Accident Report |
Name, Code No. and address of the factory/establishment(Seal) |
| Signature of the Employer/Authorised Signatory] |
204[Reg. Form 13
(In Duplicate)*
Death Certificate
(For Dependant's Benefit or Funeral Expenses)
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulations 79 and 95-C)
Book No. . . . . . . . . . . . . . Stamp of DispensarySl. No. . . . . . . . . . . .
Name of the deceased Insured Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s/w/d of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Insurance No. . . . . . . . . . . . . . . . . . .. .
I certify that in my opinion the above named deceased Insured Person died on the . . . . . . . . . day of . . . . . . . . . . . . . . as a result of an injury/due to* . . . . . . . . . . . . . . . . . I **had been attending him/her for providing medical benefit before his/her death and I attended him/her for the last time on the . . . . . . . . . . . . . . . . day of . . . . . . . . . .
Signature . . . . . . . . . . . . . . . . . .
Insurance Medical Officer/I.M.P.
Name in block letters and rubber stamp
Any other remarks by the Medical Officer
Dated: . . . . . . . . . . . . .
*Please indicate the name of the disease
** May be suitably amended if the Insurance Medical Officer/I.M.P. has not attended the deceased person before his/her death.]
205[Reg. Form 14
Claim for Permanent Disablement Benefit
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 76-A)
I s/w/d of
Insurance No.having been declared as permanently disabled by the
Medical Board/Medical Appeal Tribunal/Employees' Insurance Court, claim Permanent Disablement Benefit accordingly.
The amount due may be paid to me by ECS as per details of my Bank given below or in cash at Branch Office:
Name of the Bank .
Branch Name ..
A/C number .
MICR number .
Signature or Thumb impression of the Claimant
Name in block letters ..
and address
Dated
| Important: |
Any person who makes a false statement or misrepresentation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishment with imprisonment for a term which may extend up to six months or with a fine up to Rs 2000 or with both.] |
206[Reg. Form 15
Claim Form for Dependant's Benefit
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 80)
Name of the deceased Insured Person . . . . . . . . . . . . . . . . . . . . . . . . . . . Ins. No. . . . . . . . . . . . . . . . . . . . S/W/D of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Death . . . . . . . . . . . . . . . . . . . . . . . . . . Last employed as . . . . . . . . . . . . . . . . . . . . . . . . . . by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I/We the following, being dependants of the above named deceased Insured Person, hereby claim and accordingly apply for dependant's benefit on account of his/her death:
| Name of the dependant |
Sex |
Age or year of birth |
Marital status |
Relationship with the deceased |
Present Address |
Name of guardian in case of minor |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
| |
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| |
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I/We declare that the particulars given above are true to the best of my/our knowledge and belief
I/We also declare that to the best of my/our knowledge and belief, there is no other dependant entitled to claim Dependant's Benefit in r/o the death of the above noted deceased I.P., save and except those mentioned above
| |
Signature* |
.png) |
1 . . . . . . . . . . . . . . . . |
| 2. . . . . . . . . . . . . . . . |
| 3. . . . . . . . . . . . . . . . |
| 4. . . . . . . . . . . . . . . . |
ATTESTATION*
Certified that the declaration, as made above, are true to the best of my knowledge and belief
| |
|
|
| |
Name in block letters and Rubber Stamp or Seal of the Attesting Authority |
Signature . . . . . . . . . . . . . . . . . . . . Designation . . . . . . . . . . . . . . . . . . |
| |
|
|
* All major dependants should sign individually and the guardian to sign in case of a minor dependant.
* This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Departments of Government, or (ii) a Municipal Commissioner, or (iii) a Workmen's Compensation Commissioner, or (iv) the Head of the Gram Panchayat under the official seal of the Panchayat, or (v) M.L.A./M.P., (vi) Gazetted Officer, or (vii) a member of Local Committee/Regional Board of ESI Corporation, or (viii) any other authority considered appropriate by the Branch Manager.
| Important: |
Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs 2000, or with both. |
207[Reg. Form 16
Claim for Dependants' Benefit
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 83-A)
| Name of the deceased employee Ins. No. I ., being the (relationship) of the above-named deceased employee and also being his/her dependant, do hereby claim Dependants' Benefit. |
| The amount due may be paid to me by ECS as per details of my Bank given below or in cash at Branch Office: |
| Name of the Bank |
| Branch Name . |
| A/C number . |
| MICR number . |
| I also declare that. |
| *(i) I have not married/re-married, so far (Applicable only in case of a female dependant). |
| *(ii) I have not attained the age of 18 years (Applicable in case of minor male/female dependant) |
| *(iii) I am still infirm. |
| (Applicable only in case of a legitimate/adopted*infirm son or a legitimate/adopted* unmarried infirm daughter who has attained the 25 years of age. The claim to be accompanied, if required, by a certificate of specified authority). |
| Dated . |
| **Signature or Thumb impression of the Claimant |
| Present Address |
| Name in block letters of Claimant/Guardian or **Signature or Thumb-impression of the Claimant for .. |
| (Name of the minor Dependant) |
| Through . |
| (name of the Guardian) |
| His/her |
| (relationship with the Minor) |
| *Please strikeout whichever is not applicable. |
| **Applicable in the case of a claim by a major Dependant. |
| ***Applicable in the case of a claim for a minor dependant. |
| [Please refer to Rule 58 of the ESI (Central) Rules, 1950].] |
208[Form 17
Certificate/Notice of Pregnancy
Maternity Benefit
(Regulations 87 and 87-A)
EMPLOYEES' STATE INSURANCE CORPORATION
Signature or thumb impression of the Insured Women
Employer's Code No. . . . . . . . . . . . .Book No. . . . . . . . . . . . . . . .
Insured Woman's Name. . . . . . . . . . . . . . .Serial No. . . . . . . . . . . . . . . .
Insurance No. . . . . . . . . . . . . . . .
Stamp of the Dispensary
Certified that I have examined the above mentioned Insured Woman and that in my opinion she is pregnant and her pregnancy appears to be . . . . . . . . . . . . . . . . . weeks old.
Or (proposed to be incorporated)
Certified that I have examined the original Agreement of embryo implantation executed between commissioning mother with the other woman. I have also examined certificate of embryo implantation issued by the Assisted Reproductive Technology Clinic recognized by Indian Council of Medical Research.
Date . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
Signature or counter-signature of Insurance Medical Officer
. . . . . . . . . . . . . . .
Name in Block Letters and
Rubber Stamp
Any other remarks . . . . . . . . . . . . . . . . . . . . .
I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Insurance No. . . . . . . . . . . . . . . Wife/daughter of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hereby give notice of pregnancy.
Or
I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Insurance No. . . . . . . . . . . . . . . Wife/daughter of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . hereby submit the copy of agreement for commissioning.
Present address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Present/last employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date: . . . . . . . . . . . .
. . . . . . . . . . . .
Signature or thumb-impression
of the Insured Woman]
209[Reg. Form 18
Certificate of Expected Confinement/Confinement/Miscarriage Maternity Benefit
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulations 88 and 89)
Signature or thumb impression of the Insured Women
Employer's Code No. . . . . . . . . . . . .Book No. . . . . . . . . . . . . . . .
Serial No. . . . . . . . . . . . . . . .
Insured Woman's Name. . . . . . . . . . . . . . .
Insurance No. . . . . . . . . . . . . . . .
Wife/Daughter of. . . . . . . . . . . . . . .
Stamp of the Dispensary
I*. Certified that I have examined the abovementioned Insured Woman today and that in my opinion she may expect to be confined on or about . . . . . . . . . . . . . . . . . . . . . . .
II*. Certified that I attended the abovementioned Insured Woman in connection with her confinement/miscarriage at . . . . . . . . . . . . . . . . . . . . . . . (address) and that she was there delivered of a child on the . . . . . . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . .
Signature of midwife, if any
Date: . . . . . . . . . . . . . . .
Any other remarks . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Signature or counter-signature of
the Insurance Medical Officer
Name in block letters and
Rubber Stamp
*Delete whichever is not applicable.
210[Form 19
Claim for Maternity Benefit and Notice of Work
[Existing Regulations 88(ii), 89 & Regulation 91,
New Added Regulations 88(iv), 89-C, and 89-D]
EMPLOYEES' STATE INSURANCE CORPORATION
Signature or thumb impression of the Insured Women
Book No. . . . . . . . . . . . . . . .
Serial No. . . . . . . . . . . . . . . .
Employer's Code No. . . . . . . . . . . . . . .
Insured Woman's Name. . . . . . . . . . . . . . .
Insurance No. . . . . . . . . . . . . . .
Wife/Daughter of . . . . . . . . . . . . . . . . . . .
Stamp of the Dispensary . . . . . . . . . . . . . . . . . . .
I, the above mentioned Insured Woman hereby claim Maternity Benefit for expected confinement or confinement* or miscarriage of self or commissioning mother or Adopting mother with effect from . . . . . . . . . . . . . . . . . . .
I, further declare that I have ceased*/shall cease to work for remuneration with effect from the aforesaid date.
*I, do hereby give notice that I have taken up/shall take up work for remuneration with effect from the . . . . . . . . . . . . . . . . . . . I have drawn maternity benefit only upto . . . . . . . . . . . . . . . . . . .
*** I hereby declare that as on date I have the following child/children and I do hereby declare that the information furnished is true and nothing has been concealed.
| Sl. No. |
Name of IW |
Gender |
Date of birth |
| First Child |
|
|
|
| Second Child |
|
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|
| Third Child |
|
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|
| Fourth Child |
|
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|
Present/Last Employer** . . . . . . . . . . . . . . . . . . . . .
Department, shift and occupation . . . . . . . . . . .
Present address . . . . . . . . . . . . . . . . . . . . . . . . . .
Signature or thumb-impression of the Insured Woman
Date . . . . . . . . . . . . . .Name of the Branch Office . . . . . .
* Please delete whichever is not applicable.
** If not in employment, mention the particulars of last employer.
*** The above declaration is not applicable for commissioning mother and adoptive mother.
Important:
1. No work for remuneration shall be taken up during the period for which Maternity Benefit is claimed or is to be claimed.
2. For resumption of work must be sent before any work is taken up.
3. If Commissioning mother and other woman both are Insured Woman then the claim will be provided only to the commissioning mother. Claim against miscarriage will also not be payable to the commissioning as well as to the other woman.
4. In case annulment of adoption approved by the Court, Insured Woman shall refund the entire amount of maternity benefit paid to her.
5. In case Insured woman gives birth of twin child such claim shall be treated a single claim.
6. A person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offense punishable with imprisonment for a term which may extend up to six months, or with a fine up to Rs 2,000/- or with both.
211[Reg. Form 20
Claim for Maternity Benefit after the death of an Insured Woman leaving behind the Child
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 89-A)
Claim arising from the death on . . . . . . . . . . . . . . . . . of Ms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. wife/daughter of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . having Insurance No. . . . . . . . . . . . . . . . and last employed by M/s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., *being related to the above named deceased Insured Person as her . . . . . . . . . . . . . . . . . . . . . . . . . . . .and being her nominee/being her legal representative (applicable if the I.W. dies leaving no nominee), hereby claim Maternity Benefit for the period from . . . . . . . . . . . to . . . . . . . . . . . . .
I also declare that
**(i) the deceased Insured Woman died on . . . . . . . . . . . . . . leaving behind the child who is still alive; or
**(ii) the deceased Insured Woman died on . . . . . . . . . . . . . . leaving behind the child who also died on . . . . . . . . . . .
The amount due may be paid to me by Money Order/in cash at Branch Office
I further declare that the particulars, as given hereinabove, are true to the best of my knowledge and belief
Date . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Signature/Thumb impression of the Claimant
Name in block letters and . . . . . . . . . . . .
Address of claimant . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ATTESTATION
***Certified that the declarations, as made hereinabove, are true to the best of my knowledge and belief
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Name in block letters and Rubber Stamp or Seal of the Attesting Authority |
Signature with date . . . . . . . . . . . Designation . . . . . . . . . . . . . . . . . . . . . . . |
| |
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|
* Strike out this line if not applicable
** Delete either (i) or (ii), as may not be applicable in the case
*** This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (iv) the Head of Gram Panchayat under the official seal of the Panchayat, or M.L.A./M.P.; or (v) a Gazetted Officer of the Central/State Government/Member of the Local Committee/Regional Board; or (vi) any other authority considered as appropriate by the Branch Manager concerned.
| Important:1. |
This claim form, duly filled up, is required to be submitted to the appropriate Branch Office, together with a death certificate in form 24-B, within 30 days of the death of the Insured Woman. |
| 2. |
Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs 2000 or with both. |
212[Reg. Form 21
Death Certificate in case of Confinement for Claiming Maternity Benefit
EMPLOYEES' STATE INSURANCE CORPORATION
(Under Regulation 89-A)
Stamp of the Dispensary
| Book No. . . . . . . . . . . . . . . . |
Name of the deceased |
| |
Insured woman . . . . . . . . . . . . . . . . . . . . . |
| Serial No. . . . . . . . . . . . . . . . |
W/D of . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
Insurance No. . . . . . . . . . . . . . . . . . . . . . . |
I certify that in my opinion
(i) the above named deceased Insured Woman died on . . . . . . . . . . . . as a result of . . . . . . . . . during her confinement/*during a period of . . . . . . . . . . . . . . . . . . . . . . . . . . weeks . . . . . .
(Cause of death)
immediately following her confinement, leaving behind the child
*(ii) the said child also died on . . . . . . . . . . . . . . . . . . . . . . . as a result of . . . . . . . . . . . . . . . . . .
Also certified that I had been attending her*/and also her said child for providing medical benefit before *her death/her said child's death and I attended her for the last time on . . . . . . . . . . . . . . . . . . . . and her said child for the last time on . . . . . . . . . . . . . . . . . .
Any other remarks
. . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . . .Signature of Insurance Medical Officer/
Insurance Medical Practitioner
Rubber Stamp and name In block letters
Note: (1) Please delete whichever is not applicable
(2) The language may be suitably amended if the Insurance Medical Officer/Insurance Medical Practitioner had not attended the deceased person before her/her child's death.
213[Reg. Form 22
Funeral Expenses Claim Form
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 95-E)
Claim arising out of death on . . . . . . . . . . . . . . . . . . . of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s/w/d of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .aged . . . . . . years, having Insurance No.
and last employed as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . by
M/s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Code No. . . . . . . . . . . . .
I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s/w/d of . . . . . . . . . . . . . . . . . . . . aged . . . . . . . . . . . . . . . . . . . years declare:
*(i) that I am the eldest surviving member of the family of the deceased Insured Person, whose particulars are furnished hereinabove, and that I actually incurred an expenditure of Rs. . . . . . . . . . . (Rupees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . only) necessary for the funeral of the said deceased person
or
*(ii) that the deceased insured Person, whose particulars are furnished thereinabove, did not have a family/was not living with his/her family at the time of his/her death and that I actually incurred an expenditure of Rs . . . . . . . . . . . . . . . (Rupees . . . . . . . . . only) on the funeral of the deceased Insured Person
Accordingly, I do hereby claim funeral expenses for the amount of Rs . . . . . . . . . . . . . . . . (Rupees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . only)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . . . .Name in block letters
Signature/Thumb impression of the Claimant
ATTESTATION
** Certified that the declarations, as made hereinabove, are true to the best of my knowledge and belief
| |
|
|
| |
Name in block letters and Rubber Stamp or Seal of the Attesting Authority |
Signature. . . . . . . . . . . . . . . . . . . . Designation . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . . |
| |
|
|
* Delete either (i) or (ii) which may not be applicable in the case
** This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (iv) the Head of Gram Panchayat under the official seal of the Panchayat, or M.L.A./M.P.; or (v) a Gazetted Officer of the Central/State Government, Local Committee/Regional Board; or (vi) any other authority considered as appropriate by the Branch Manager concerned
| Important: |
Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs 2000 or with both. |
| Note: |
In the case of a minor, the guardian should sign the claim form on behalf of the minor and then add the following below his/her signature: |
-----------------------------
(Name of the Minor)
through-----------------------------
(Name of the Guardian)
his/her-----------------------------
(Relationship with the Minor)]
214[Reg. Form 23
(To be submitted along with claim of June and December)
Life Certificate for Permanent Disablement Benefit
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 107)
Insurance No. of permanently disabled person
* Certified that Shri/Smt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . w/s/d of . . . . . . . . . . . . . . . . . . . . is alive this . . . . . . . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . 20 . . . . . . .
Signature . . . . . . . . . . . . . . . . .
Name in block letters of
signing Claimant. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Designation with Rubber Stamp/Seal
Date . . . . . . . . . . . . . .of the Attesting Authority
| Important: |
Any person who makes a false statement or misrepresentation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs 2000 or with both. |
| * |
This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (iv) the Head of Gram Panchayat under the official seal of the Panchayat; or (v) M.L.A./M.P.; or (vi) a Gazetted Officer of the Central/State Government; or (vii) a member of the Regional Board/Local Committee of the ESIC; or (viii) any other authority considered as appropriate by the Branch Manager concerned. |
215[Reg. Form 24
(To be submitted along with claim of June and December)
Declaration and Certificate for Dependant's Benefit
EMPLOYEES' STATE INSURANCE CORPORATION
(Regulation 107-A)
Name of the deceased Insured Person . . . . . . . . . . . . Ins. No.
I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . being the . . . . . . . . . . . . . . . . . . . . of the above named deceased Insured Person and also being his dependant, do hereby solemnly declare:
*(i) that I have not married/remarried so far
(To be given only by a female dependant)
*(ii) that I have not yet attained the age of eighteen years
(To be given only in respect of a minor male or female dependant)
*(iii) that I have attained the age of eighteen years but continue to be infirm
(To be given by a legitimate/adopted infirm son or by a legitimate/adopted infirm daughter.
Certificate as specified, to be attached, if required)
Present Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . . . . .Signature or thumb impression
of the dependant
or
| Name in block letters of |
. . . . . . . . . . . . . . . . . . . . |
| signing claimant |
Signature or thumb impression of the |
| |
Guardian in case of a minor dependant |
| |
Name of the minor . . . . . . . . . . . . |
| |
Through . . . . . . . . . . . . . . . . . . |
| |
(Name of the Guardian) |
| |
his/her . . . . . . . . . . . . . . . . . . . . |
| |
(Relationship with the minor) |
CERTIFICATE
** Certified that Shri/Smt/Kumari . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . w/s/d of . . . . . . . . . . . . . . . . . . . . . is alive this day, the . . . . . . . day of . . . . . . 20 . . . . . and that the declarations made above are true to the best of my knowledge and belief
| |
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|
| Date . . . . . . . . . . |
Name in block letters and Rubber Stamp or Seal of the Attesting Authority |
Signature . . . . . . . . . . . . . . . Designation . . . . . . . . . . . . . . |
| |
|
|
* Strike out whichever is not applicable.
** This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (iv) the Head of Gram Panchayat under the official seal of the Panchayat; or (v) M.L.A./M.P.; or (vi) a Gazetted Officer of the Central/State Government; or (vii) a member of the Regional Board/Local Committee of the ESIC; or (viii) any other authority considered as appropriate by the Branch Manager concerned.
| Important: |
Any person who makes a false statement or misrepresentation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs 2000 or with both.] |
Challan Form for Deposit in A/c No. 1
EMPLOYEES' STATE INSURANCE CORPORATION
Instructions: To be submitted in four copies.
(i) Original for Bank.
(ii) Duplicate for ESIC, through Bank.
(iii) Triplicate for depositor.
(iv) Quadruplicate for depositor to be attached with Return of Contribution.
DateMonthYear
Employer's Code Bank & Branch Code
Name of Factory/Estt. & Address
Mode of Payment [Tick ( ) mode used]CashChequeD.D.
Cheque/D.D. No.Date
MonthYear
Draw on (Name of the Bank) ------------------------ Period of Contribution
Detail of Payment [Tick ( ) mode used] Regular ContributionInterestDamagesOther
No. of EmployeesTotal Wages
Rs.P.
Employee Contribution
Employer's Contribution
Interest
Damages .
Others
Total
Total amount (in words)-----------------------------------------------------------------------------------
R.O. Demand Letter No. & Date-------------------------------------------------------------------------
----------------------------
Signature
------------------------------------------------------------
Name & Designation-Seal of Authorised Signatory
| (to be filled by Depositor) |
(Acknowledgement) |
For use in Bank |
| Received Rs. (Rs. Only) In cash/by cheque/DD No. Date (Subject to Realisation) drawn on (Bank in favour of ESIC A/c No. 1 |
Bank Scroll No. Date Authorised Signature & Seal of the Receiving Bank |
| (For Bank Branch Code see on reverse) |
Note: Please put cross(X) mark in blank boxes. |
Photo Identity Card Form
EMPLOYEES' STATE INSURANCE CORPORATION
Insurance No.Employee's Code No.
Name (In block Capital)
Father's/Husband's Name
Present Address
Pin Code
Local OfficeSexDispensary
Marital status (state whether Unmarried/Married or Widow/Widower)
AgeYear of Birth----
Particulars of Employment
(a) Date of appointment----
(b) Whether employees directlyThrough contractor
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| (d) Nature of work |
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| (e) Name of Nominee |
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| (f) Details of family members |
| S. No. |
Name |
Date of Birth |
Relationship with insured person |
Whether residing with him/her or not |
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| Signature or thumb impression of the insured person |
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| Verified by Employer's Signature with Seal Date |
|
Date |
SCHEDULE I
(Omitted)216
SCHEDULE II
(Omitted)217
218[SCHEDULE III
COMMUTATION VALUES FOR PERMANENT DISABLEMENT BENEFIT
(Regulation 76-B)
| Age last birthday of insured person on thedate on which the application for commutation is received in the appropriate office |
The factor with which the daily rate ofbenefit is to be multiplied |
| 1 |
2 |
| 17 years and below |
5690 |
| 18 years |
5670 |
| 19 years |
5660 |
| 20 years |
5640 |
| 21 years |
5620 |
| 22 years |
5600 |
| 23 years |
5580 |
| 24 years |
5560 |
| 25 years |
5540 |
| 26 years |
5510 |
| 27 years |
5480 |
| 28 years |
5460 |
| 29 years |
5420 |
| 30 years |
5390 |
| 31 years |
5360 |
| 32 years |
5320 |
| 33 years |
5280 |
| 34 years |
5240 |
| 35 years |
5200 |
| 36 years |
5160 |
| 37 years |
5110 |
| 38 years |
5070 |
| 39 years |
5020 |
| 40 years |
4970 |
| 41 years |
4910 |
| 42 years |
4860 |
| 43 years |
4800 |
| 44 years |
4740 |
| 45 years |
4670 |
| 46 years |
4610 |
| 47 years |
4540 |
| 48 years |
4470 |
| 49 years |
4400 |
| 50 years |
4330 |
| 51 years |
4250 |
| 52 years |
4180 |
| 53 years |
4100 |
| 54 years |
4020 |
| 55 years |
3930 |
| 56 years |
3850 |
| 57 years |
3760 |
| 58 years |
3670 |
| 59 years |
3590 |
| 60 years |
3500 |
| 61 years |
3400 |
| 62 years |
3310 |
| 63 years |
3220 |
| 64 years |
3130 |
| 65 years |
3030 |
| 66 years |
2940 |
| 67 years |
2850 |
| 68 years |
2750 |
| 69 years |
2660 |
| 70 years |
2570 |
| 71 years |
2470 |
| 72 years |
2380 |
| 73 years |
2290 |
| 74 years |
2200 |
| 75 years |
2120 |
| 76 years |
2030 |
| 77 years |
1950 |
| 78 years |
1860 |
| 79 years |
1780 |
| 80 years |
1700] |