Download ESIC FORM 20 CLAIM FOR MATERNITY BENEFIT AFTER THE DEATH OF AN INSURED

Download ESIC FORM 20

Download ESIC FORM 20 CLAIM FOR MATERNITY BENEFIT AFTER THE DEATH OF AN INSURED WOMAN LEAVING BEHIND THE CHILD EMPLOYEES’ STATE INSURANCE CORPORATION

As per ESIC Regulation 89-A

89A. Claim for maternity benefit after the death of an insured woman leaving behind the child

For the purposes of the proviso to sub-section (2) of section 50 of the Act, the person nominatedby the deceased insured woman on Form 1 or on such other Form as may be specified by the Director General in this behalf and if there is no such nominee, the legal representative, shall submit to the appropriate office by post or otherwise a claim for maternity benefit, as may be due, in [Form 20] within 30 days of the death of the insured woman together with a death certificate in [Form 21] given in accordance with these Regulations.

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Download ESIC Reg. Form :19 CLAIM FOR MATERNITY & NOTICE OF WORK EMPLOYEES’ STATE INSURANCE CORPORATION

Download ESIC Reg. Form – 19

Download ESIC Reg. Form – 19 CLAIM FOR MATERNITY & NOTICE OF WORK EMPLOYEES’ STATE INSURANCE CORPORATION

As per ESIC Regulation 88, 89 & 91

88. Claim for maternity benefit commencing before confinement Every insured woman claiming maternity benefit before confinement shall submit to the appropriate local office by post or otherwise—

(i)      a certificate of expected confinement in [Form 18] given in accordance with these regulations,not earlier than fifteen days before the expected date of confinement;

(ii)     a claim for maternity benefit in [Form 19] stating therein the date on which she ceased orwill cease to work for remuneration.

(iii)  within thirty days of the date on which her confinement takes place, a certificate of confinement in [Form 18] given in accordance with these regulations.

89. Claim for maternity benefit only after confinement or for miscarriage

Every insured woman claiming maternity benefit for miscarriage shall within 30 days of the date of the miscarriage, and every insured woman claiming maternity benefit after confinement, shall submit to the appropriate office by post or otherwise a claim for maternity benefit in: [Form 19] together with a certificate of confinement or miscarriage in [Form 18] given in accordance with these regulations.

91.Notice of work for remuneration Except as provided in regulation 89B every insured woman who has claimed maternity benefit shall give notice in [Form 19] if she does work for remuneration on any day during the period for which maternity benefit would be payable to her but for her working for remuneration.

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Download ESIC REG. FORM-16 CLAIM FOR PERIODICAL PAYMENTS OF DEPENDANTS’ BENEFIT EMPLOYEES' STATE INSURANCE CORPORATION

Download ESIC REG. FORM-16 

As per ESIC Regulation 83 – A. Submission of claims for periodical payments of dependants’ benefit

Each dependant whose claim for dependants’ benefit is admitted under regulation 82, shall submit to the appropriate [branch office], by post or otherwise, a claim covering, except in the case of first or a final payment, a period of one or more complete calendar months in [Form 16]. Such claim may be made by the legal representative of a beneficiary or in the case of a minor by his guardian.

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Download ESIC REG. FORM -15 CLAIM FORM FOR DEPENDANT'S BENEFIT EMPLOYEES' STATE INSURANCE CORPORATION

Download ESIC REG. FORM -15

As per ESIC Regulation 80 Submission of claim for dependants’ benefit

(1)     A claim for dependants’ benefit shall be submitted to the appropriate [branch office] by post or otherwise in [Form 15] by the dependant or dependants concerned or by their legal representative or, in case of a minor, by his guardian, and such claim shall be supported by documents proving—

(i)      That the death is due to an employment injury;

[(ii) That the person claiming is a dependant entitled to claim as provided in rule 58 of the Employees’ State Insurance (Central) Rules, 1950.]

(iii)  The age of the claimant;

(iv)  the infirmity of the dependant claiming to be infirm within the purview of [rule 58 of the Employees’ State Insurance (Central) Rules, 1950] by a certificate of such medical or other authority as the Director General may, by a general or special order specify in this behalf.

PROVIDED that where the appropriate regional office is satisfied about the bona fides of the applicant or about the truth of the facts relating to any of the matters mentioned above, one or more of the documents may be dispensed with.

(2)     The following may be accepted as proof of age—

(a)     Certified extract from an official record of births showing the date and place of birth

and father’s name;

(b)     Original horoscope prepared soon after birth;

(c)     certified extract from baptismal register;

(d)     certified extract from school record showing the date of birth and father’s name;

(e)     Such other evidence as may be acceptable to the appropriate Regional Office in the

circumstances of a particular case.

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Download ESIC FORM :14 CLAIM FOR PERMANENT DISABLEMENT BENEFIT EMPLOYEE.S STATE INSURANCE CORPORATION

 Download ESIC FORM – 14

As per Regulation 76 – A  Submission of claims for permanent disablement benefit

An insured person who has been declared to be permanently disabled by a Medical Board or by an Appeal Tribunal shall submit, by post or otherwise, to the appropriate [branch office] a claim, covering, except in the case of a first payment, a period of one or more complete calendar months in [Form 14] for claiming permanent disablement benefit.

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Download ESIC FORM 12 For : E.S.I. CORPORATION

Download ESIC FORM 12

As per ESIC Regulation 68  Report of accident by an employer

Every employer shall send a report in [Form 12] to the nearest [Branch Office] and to the nearestinsurance medical officer—

(i)      immediately if the injury is serious, i.e. it is likely to cause death or permanent disablementor loss of a member; and

(ii)     in any other case within 24 hours after the receipt of the notice under regulation 65 or ofthe time when the accident came to the notice of the employer or of a foreman or other official under whose supervision the insured person was employed at the time of the accident or any other person designated for the purpose by the employer :PROVIDED that in case of a serious injury, and particularly when the injury results in death at the place of employment, the report to the Insurance Medical Officer and the [Branch Office] shall be sent through a special messenger, or otherwise, as speedily as may be practicable under the circumstances

PROVIDED FURTHER that where a report of the accident is made by the employer under the Factories Act, 1948, the report to the local office and to the insurance medical officer may be made in the same form as is prescribed under the Factories Act, 1948, provided that all the additional information required under [Form 12] is added thereto:

PROVIDED FURTHER that it shall not be necessary for the employer to send a report in Form

16 if an employment injury is caused by any occupational disease specified in Schedule III to the Workmen’s Compensation Act, 1923; but the employer shall furnish on demand to the appropriate [branch office], within such reasonable period as may be specified, such information and particulars as shall be required of the nature of and other relevant circumstances relating to any employment specified in Schedule III to the Workmen’s Compensation Act, 1923.

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Download ESIC FORM 11 For :ACCIDENT BOOK EMPLOYEES' STATE INSURANCE CORPORATION

Download ESIC FORM 11

Download ESIC FORM 11 ACCIDENT BOOK EMPLOYEES’ STATE INSURANCE CORPORATION

As per Regulation 66 Every employer shall—

(i) Keep a book readily accessible (hereinafter called ‘the Accident Book’) in [Form 11], in whichthe appropriate particulars of any accident causing personal injury to an insured person may be entered;

(ii) Preserve every such book when it is completed for a period of five years from the date of the last entry thereon:

PROVIDED that it shall be necessary to enter in the said Accident Book particulars of any employment injury caused by an occupational disease specified in Schedule III to the Workmen’s Compensation Act, 1923:PROVIDED FURTHER that an employer shall be deemed to have complied with this regulation sufficiently if in any register maintained by him, the appropriate particulars are also shown.

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Download ESIC REG. FORM – 9 For CLAIM FOR SICKNESS/T.D.B./MATERNITY BENEFIT

Download ESIC REG. FORM – 9

Download ESIC REG. FORM – 9 CLAIM FOR SICKNESS/T.D.B./MATERNITY BENEFIT FOR SICKNESS EMPLOYEES’ STATE INSURANCE CORPORATION

As per ESIC Regulation 63 & 89-B 63. Form of claim for sickness or temporary disablement

An insured person intending to claim sickness benefit or disablement benefit for temporary disablement shall submit to the appropriate [branch office] by post or otherwise, a claim for benefit in [Form 9], appropriate to the circumstances of the case together with the appropriate medical certificate :

PROVIDED that where only one claim in [Form 9] is submitted in respect of more than one certificate, such [Form 9] shall be deemed to be appropriate to all such certificates.

89B. Claim for maternity benefit in case of sickness arising out of pregnancy, confinement, premature birth of child or miscarriage

(1) Every insured woman claiming maternity benefit in case of sickness arising out of pregnancy,confinement, premature birth of child or miscarriage, shall submit to the appropriate office by post or otherwise a claim for benefit in one of the [Forms 9], appropriate to the circumstances of the case together with the appropriate medical certificate in [Form 7 or 8], as the case may be, given in accordance with the Regulations.

(2) The provisions of regulations 55 to 61 and 64 shall, so far as may be, apply in relation to a claim submitted and a certificate given in accordance with this regulation as they apply to certification and claims under those regulations.

Download ESIC REG. FORM – 9

Download ESIC REG. FORM – 9 CLAIM FOR SICKNESS/T.D.B./MATERNITY BENEFIT FOR SICKNESS EMPLOYEES’ STATE INSURANCE CORPORATION

As per ESIC Regulation 63 & 89-B

I______________________________________ Insurance No. __________________ s/w/d of _____________________________ hereby claim Cash Benefit for period over leaf 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 diabled/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 a false statement or misrepresentation for the purpose of obtaining benefitwhether for himself/some other person shall be punishable with imprisonment up to 6 months or with a fine up to Rs. 2,000/- or with 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.

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Download ESIC FORM 6 For :Register of Employees

 Download ESIC FORM 6 For  REGISTER OF EMPLOYEES EMPLOYEES’ STATE INSURANCE CORPORATION

As per ESIC Regulation 32  Register of employees

(1) Every employer shall maintain a register in [Form 6] in respect of every employee of his factory or establishment.[(1A) Register of employees engaged by immediate employer: Every immediate employer shallmaintain a register in [Form 6] in respect of every employee engaged by him and submit the same to the principal employer before the settlement of any amount payable under sub-section (1) of section 41 of Act.]

(2) Every employer shall preserve every register maintained under this regulation after it is filled, for a period of five years from the date of last entry therein.

(3) The employer shall give a reasonable opportunity to any of his employees, if he so desires, to see entries in respect of such employee in this register once a month.]

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Download ESIC FORM 5-A For EMPLOYEES' STATE INSURANCE CORPORATION

Download ESIC FORM 5-A EMPLOYEES’ STATE INSURANCE CORPORATION

As per ESIC Regulation 31-Second Provison Time for payment of contribution

An employer who is liable to pay contributions in respect of any employee shall pay those contributions within 21 days of the last day of the calendar month in which the contributions fall due:]

[PROVIDED that where a factory/establishment is permanently closed, the employer shall pay contribution on the last day of its closure:]

[PROVIDED that an employer may opt, in such manner as may be prescribed, by the Director-General for payment of amount in advance towards contribution to be adjusted against contributions payable by him (including employees’ contribution) for a wage period so that the balance of advance amount continues to be more than the contributions due and payable at the end of the concerned wage period. Such an employer shall furnish in the prescribed proforma [(Form 5A)], a six monthly statement of contributions payable and paid in advance with the balance left at the end of each month along with return of contributions to the appropriate Regional Office of the Corporation.]

 

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