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.

This movie requires Flash Player 9

Leave a Reply

Your email address will not be published. Required fields are marked *