Employees' State Insurance General Regulations 1950

8/14/2019 Employees' State Insurance General Regulations 1950

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EMPLOYEES STATE INSURANCE (GENERAL)

REGULATIONS, 1950

[RS/5/48, DATED 17-10-1950

In exercise of the powers conferred by section 97 of the Employees State Insurance Act,

194 !"4 of 194#, the Employees State Insurance $orporation is pleased to ma%e the

followin& re&ulations, the same ha'in& been pre'iously published as re(uired by sub)section !1# of the said section, namely*+

CHAPTER I

S!"#$ $%$&' * '+$'$

1. (1) These regulations may be called the Employees !tate Insurance ("eneral)

Regulations# 1$%&.(') They etend to the hole o* India including the +nion Territory o* Pondicherry

ecept the !tate o* ,ammu and -ashmir.

D'%%$%".

'. In these regulations# unless the contet otherise reuires/

(a) 0Act means the Employees !tate Insurance Act# 1$23 (42 o* 1$23)5

(b) 0appointed day means ith re*erence to any area# *actory or establishment# the day

*rom hich the hole o* Chapters I6 and 6 o* the Act apply to such area# *actory or

establishment# as the case may be5(c) 0Appropriate 7**ice# 0Appropriate 1[ranch office or 0Appropriate Regional

7**ice# shall mean ith re*erence to any action ta8en under these regulations# sucho**ice o* the Corporation as may be speci*ied *or that purpose under a general or

special order o* the Corporation5

(d) 0Central Rules means the rules made by the Central "o9ernment under section $%

o* the Act5

(e) 1a:;;;orm including the Temporary Identi*ication Certi*icate and obtain the signature or the

thumb impression o* such person and also complete the *orm as indicated thereon.

(') Fhere an Identity Card is produced under such subregulation (1)# the employer shall

ma8e rele9ant entries thereon.

14. '&:; ; ;orm 2 *or

each person in respect o* hom an insurance number is allotted and shall include in suchcard the particulars o* the *amily entitled to medical bene*it under regulation $%A and

shall send all such identity cards to the employer. !uch employer shall i* and hen the

employee has been in his ser9ice *or '%:4 months


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1$. '3:;;;orm

41a[8along ith receipted copies o* challans *or the amounts deposited in the an8# to

the appropriate o**ice by registered post or messenger# in respect o* all employees *orhom contributions ere payable in a contribution period# so as to reach that o**ice as/

4':(a) ithin 2' days o* the termination o* contribution period to hich it relatesor the purposes o* section o* the Act# the due date by hich the e9idence o*

contributions ha9ing been paid must reach the Corporation shall be the last o* the days

respecti9ely speci*ied in clauses (a)# (b) M (c) o* subregulation (1).inancial Reconstruction# may G/
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(a) in case o* a change o* management including trans*er o* underta8ing(s) to or8er(s)

cooperati9e or in case o* merger or amalgamation o* sic8 industrial company ith a

healthy company# completely ai9e the damages le9ied or le9iable5

(b) in other cases# depending on its merits# ai9e up to %& per cent damages le9ied orle9iable5

(c) in eceptional hard cases# ai9e either totally or partially the damages le9ied orle9iable.orm a[10and ithin such time as the said o**ice may in riting reuire in the said >orm.ICATI7= A=D CBAI?! >7R !IC-=E!! A=D TE?P7RARDI!ABE?E=T

E%*'' " .%;'.. * $'2"##3 *%.6&''$

%4. E9ery insured person# claiming sic8ness bene*it or disablement bene*it *or temporary

disablement# shall *urnish e9idence o* sic8ness or temporary disablement in respect o* thedays o* his sic8ness or temporary disablement by means o* a medical certi*icate gi9en by

an Insurance ?edical 7**icer in accordance ith these regulations in the *orm

appropriate to the circumstances o* the caseG

P#"%*'* that in areas here arrangement *or medical bene*it under the Employees

!tate Insurance Act ha9e not been made or otherise i* in its opinion the circumstanceso* a particular case so @usti*y# the Corporation may accept any other e9idence o* sic8ness

or temporary disablement in the *orm o* a certi*icate issued by the medical o**icer o* the

!tate "o9ernment# local body or other medical institution# or a certi*icate issued by any

registered medical practitioner containing such particulars and attested in such manner asmay be speci*ied by the Director"eneral in this behal*.

P'#.". "2'$'$ $" %..' '*%& '#$%%$'

%2. =o medical certi*icate under these regulations shall be issued ecept by the Insurance?edical 7**icer to hom an insured person has been allotted or by an Insurance ?edical

7**icer attached to a dispensary# hospital# clinic or other institution to hich and insured

person is allotted and such Insurance ?edical 7**icer shall eamine and i* in his opinionthe condition o* the insured person so @usti*ies# issue to such insured person *ree o*

charge# any medical certi*icates reasonably reuired by such insured person under or *or

the purposes o* the Act or any other enactment or these regulationsGP#"%*'*that an Insurance ?edical 7**icer may issue a medical certi*icate under these

regulations to a insured person ho is not allotted to him or to the dispensary# hospital#clinic or other institution to hich he is attached# i* such o**icer is satis*ied that in the

circumstances o* any particular case the insured person cannot reasonably be epected to

get medical bene*it *rom the Insurance ?edical 7**icer or the dispensary# hospital# clinicor other institution to hich such insured person has been allotted5 and such certi*icate

shall also be issued *ree o* charge G
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P#"%*'* #$!'#that an insured person shall not be granted a medical certi*icate unless

he produces to the Insurance ?edical 7**icer his Identity Card or such other

0Documents as under these regulations# may ha9e been issued in lieu thereo*.

M'*%& '#$%%$'

%%. The appropriate *orm o* a medical certi*icate shall be *illed in in8 or otherise as

may be speci*ied by the Director"eneral by the Insurance ?edical 7**icer in his onhandriting and shall contain a concise statement o* the disease or disablement hich in

the opinion o* the Insurance ?edical 7**icer necessitates abstention *rom or8 on

medical grounds or renders the person temporarily incapable o* or8. The statement o*

the disease or disablement in the medical certi*icate shall speci*y the nature thereo* asprecisely as the Insurance ?edical 7**icers 8noledge o* the condition o* the insured

person at the time o* the eamination permits.

T%' " #$% '*%& '#$%%$'

%. (a) An Insurance ?edical 7**icer shall gi9e the medical certi*icate to an insured

person at the time o* the eamination to hich it relates5 here he is pre9ented *rom so

doing he shall send the certi*icate to the insured person ithin tenty*our hours

therea*ter.

(b) =o *urther medical certi*icate relating to the same eamination shall be issued# ecepthere a duplicate o* such certi*icate is reuired# in hich case it shall be issued *ree o*

charge and clearly mar8ed 0Duplicate.

3:M'*%& '#$%%$' " %#.$ '+%$%"

%. Fhere the eamination is the *irst eamination in respect o* a spell o* sic8ness or aspell o* temporary disablement# the medical certi*icate shall be in the *orm o* a *irst

certi*icate (>orm 3a[7) and shall be only in respect o* the date o* eaminationG

$:P#"%*'*that here the insured person# ho needs abstention *rom or8 on the day

o* eamination# states that he has been actually sic8 or temporarily disabled on a day

earlier than the date o* his *irst eamination# the Insurance ?edical 7**icer may# i* he issatis*ied as to the truth o* the statement that the insured person as unable to present

himsel* *or medical eamination earlier *or reasons beyond his control# certi*y incapacity

*or or8 on the date preceding the date o* eaminationGorm %b[1i* an employment in@ury is caused by any 7ccupational Disease

speci*ied in !chedule III to the For8mens Compensation Act# 1$'45 but theemployer shall *urnish on demand to the appropriate 55a[ranch7**ice# ithin

such reasonable period as may be speci*ied# such in*ormation and particulars as shall

be reuired o* the nature o* and other rele9ant circumstances relating to anyemployment speci*ied in !chedule III to the For8mens Compensation Act# 1$'4.IT

N"$%' " 2#'33. An insured oman# ho decides to gi9e notice o* pregnancy be*ore con*inement#

shall gi9e such notice in >orm $1a[17to the appropriate%%a[ranch7**ice by post or

otherise and shall submit# together ith such notice# a certi*icate o* pregnancy in >orm'& gi9en in accordance ith these regulations on a date not earlier than se9en days be*ore

the date on hich such notice is gi9en.

C&% "# $'#%$3 6''%$ "'% 6'"#' "%''$

33. E9ery insured oman claiming maternity bene*it be*ore con*inement shall submit tothe appropriate %%a[ranch7**ice by post or otherise/

(i) a certi*icate o* epected con*inement in >orm $'b[1 gi9en in accordance iththese regulations# not earlier than *i*teen days be*ore the epected date o*

con*inement5

(ii) a claim *or maternity bene*it in >orm $'c[19stating therein the date on hich she

ceased or ill cease to or8 *or remuneration5 and

(iii) ithin thirty days o* the date on hich her con*inement ta8es place# a certi*icate o*

con*inement in >orm $'b[1gi9en in accordance ith these regulations.
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C&% "# $'#%$3 6''%$ "&3 $'# "%''$ "# "# %.##%'

3$. E9ery insured oman claiming maternity bene*it *or miscarriage shall ithin 4& dayso* the date o* the miscarriage# and e9ery insured oman claiming maternity bene*it a*ter

con*inement# shall submit to the appropriate o**ice by post or otherise a claim *or

maternity bene*it in >orm $'c[19 together ith a certi*icate o* con*inement ormiscarriage in >orm $'b[1gi9en in accordance ith these regulations.

C&% "# $'#%$3 6''%$ $'# $!' *'$! " %.#'* " &'% 6'!%* $!'

!%&*

3$A. >or the purposes o* the pro9iso to subsection (') o* section %& o* the Act# theperson nominated by the deceased insured oman on >orm 1 or on such other >orm as

may be speci*ied by the Director"eneral in this behal* and i* there is no such nominee#

the legal representati9e# shall submit to the appropriate o**ice by post or otherise aclaim *or maternity bene*it# as may be due# in >orm $'d[0ithin 4& days o* the death

o* the insured oman together ith a death certi*icate in >orm $'e[1 gi9en inaccordance ith these Regulations.

C&% "# $'#%$3 6''%$ % .' " .%;'.. #%.% "$ " 2#'3,

"%''$, 2#'$#' 6%#$! " !%&* "# %.##%'

3$. (1) E9ery insured oman claiming maternity bene*it in case o* sic8ness arising out

o* pregnancy# con*inement# premature birth o* child or miscarriage# shall submit to theappropriate o**ice by post or otherise a claim *or bene*it in one o* the $4[/orm 9appropriate to the circumstances o* the case together ith the appropriate medical

certi*icate in >orm $4a[7or $4b[# as the case may be# gi9en in accordance ith these

Regulations.(') The pro9isions o* regulations %% to 1 and 2 shall# so *ar as may be# apply in relationto a claim submitted and a certi*icate gi9en in accordance ith this regulation as they

apply to certi*ication and claims under those regulations.

O$!'# '%*'' % &%' " '#$%%$'

$&. The Corporation may accept any other e9idence in lieu o* a certi*icate o* pregnancy#

epected con*inement# con*inement# death during maternity# miscarriage or sic8ness

arising out o* pregnancy# con*inement# premature birth o* child or miscarriage by an

Issurance ?edical 7**icer# i* in its opinion# the circumstances o* any particular case so

@usti*y.

N"$%' " "#; "# #''#$%"

$1. Ecept as pro9ided in regulation 3$ e9ery insured oman ho has claimedmaternity bene*it shall gi9e notice in >orm $4c[19i* she does or8 *or remuneration on

any day during the period *or hich maternity bene*it ould be payable to her but *or her

or8ing *or remuneration.
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D$' " 23'$ " $'#%$3 6''%$

$'. ?aternity bene*it shall be payable *rom the date *rom hich it is claimed pro9idedthat such date does not precede the epected date o* con*inement by more than *ortyto

days# and that no or8 is underta8en by the insured oman *or remuneration.

D%.=&%%$%" "# $'#%$3 6''%$

$4. An insured oman may be disuali*ied *rom recei9ing maternity bene*it i* she *ails

ithout good cause to attend *or or to submit hersel* to medical eamination hen so

reuired5 and such disuali*ication shall be *or such number o* days as may be decided

by the authority authorised by the Corporation in this behal*G

P#"%*'*that a oman may re*use to be eamined by other than a *emale doctor ormidi*e.

A$!"#%$3 !%! 3 %..' '#$%%$'$2. =o certi*icate reuired under any o* the regulations 3 to 3$ shall be issued ecept

by the Insurance ?edical 7**icer to hom the insured oman has or had been allotted orby an Insurance ?edical 7**icer attached to a dispensary# hospital# clinic or other

institution to hich the insured oman is or as allotted and such Insurance ?edical

7**icer shall eamine and i* in his opinion the condition o* the oman so @usti*ies or incase o* death o* the insured oman or the death o* the child# i* satis*ied about such death

issue to such insured oman or in case o* her death to her nominee or legal representati9e

as the case may be# *ree o* charge any such certi*icate hen reasonably reuired by suchinsured oman or her nominee or legal representati9e# as the case may be# under or *or

the purposes o* the Act or any other enactment or these Regulations G

P#"%*'*that such 7**icer may issue a certi*icate# as a*oresaid# under these Regulations#

to or in respect o* an insured oman ho is or as not allotted to him or to the

dispensary# hospital# clinic or other institution to hich such o**icer is attached# i* such7**icer is attending the oman *or prenatal care# *or con*inement# *or miscarriage or *or

sic8ness arising out o* pregnancy# con*inement# premature birth o* child or miscarriage or

in case o* death# as attending the deceased insured oman or the child at the time o*

death o* the insured oman or the childG

P#"%*'* #$!'# that a certi*icate o* pregnancy# o* epected con*inement# orcon*inement or miscarriage reuired under these Regulations may be issued by a

registered midi*e hich shall be accepted by the Corporation on countersignatures by

the Insurance ?edical 7**icerGP#"%*'*that such o**icer may issue a certi*icate o* pregnancy# epected con*inement or

con*inement under these regulations to an insured oman ho is not allotted to him or tothe dispensary# hospital# clinic or other institution to hich such o**icer is attached# i*

such o**icer is attending the oman *or prenatal care or *or con*inementG

P#"%*'* #$!'# that a certi*icate o* pregnancy# o* epected con*inement or o*

con*inement reuired under these regulations may be issued by a registered midi*e


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hich shall be accepted by the Corporation on counter signature by the Insurance

?edical 7**icer.

O6&%$%". " I.#' M'*%& O%'#

$%. =othing in these regulations shall relie9e an Insurance ?edical 7**icer to hom aninsured oman has been allotted# or an Insurance ?edical 7**icer attached to the

dispensary# hospital# clinic or other institution to hich an insured oman is allotted o*the obligation to eamine and i* in her opinion the condition o* the oman so @usti*ies#

issue *ree o* charge a certi*icate o* emergency# o* epected con*inement# or con*inement

or miscarriage or o* sic8ness arising out o* pregnancy# con*inement# premature birth o* a

child or miscarriage during any period in hich such insured oman is obtainingtreatment or attendance *rom any other person or *rom any other hospital or institution.

$2:?EDICAB E=E>IT T7 >A?IBIE!ailureG

Be*t

Right

''. Cardiac 6al9ular Diseases ith *ailureKcomplications

'4. Cardiomyopathies

'2. Heart Disease ith !urgical Inter9ention along ith complications6II. Chest Diseases

'%. Chronic 7bstructi9e Bung Disease (C7PD) ith congesti9e heart *ailure (Cor

Pulmonale)

6III.Diseases o* the Digesti9e !ystem

'. Cirrhosis o* li9er ith ascitiesKchronic acti9e hepatitis

I. 7rthopaedic Diseases

'. Dislocation o* 9ertebraKprolapse o* inter9ertebral disc

'3. =onunion or delayed union o* *racture

'$. Post Traumatic !urgical amputation o* loer etremity4&. Compound *racture ith chronic osteomyelitis

. Psychoses

41. !ubgroups under this are listed *or clari*ication

(a) !chiLophrenia

(b) Endogenous depression


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(c) ?anic Depressi9e psychosis (?D>)

(d) Dementia

I. 7thers

4'. ?ore than '& per cent burns ith in*ectionKcomplication

44. Chronic Renal >ailure.42. Reynauds diseaseKurgers disease.orm '1a["attested by such authority or person and in

such manner as may be speci*ied by the Director"eneral.

P'#."& $$'*' " 2'#." &%% 2'#'$ *%.6&''$ 6''%$ "#

*'2'*'$. 6''%$

1&. In the case o* claimant *or permanent disablement bene*it or dependants bene*it#

the appropriate 1&a[ranch ?anager may reuire personal attendance and dueidenti*ication o* any claimant# other than a person incapacitated by bodily illness or

in*irmity or a purdanashin lady at the appropriate '1b[ranch7**ice or at any other

o**ice o* the Corporation pro9ided that such appearance shall not be reuired more

*reuently than once in e9ery si months.


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A$#%& 2#'.'$ &' " $!' 2'#%"*%& 23'$.

1&3. '':; ; ;actoryK

Establishment

G .................................................................................

.....................................PI=......................................

.................................................................................

4. (a) Telephone =o.# i*

any............................ (b) >a =o i* any ...................................................

(c) Email address# i* any........................................

(d) =ame o* TonKRe9enue 6illage.........................

(Talu8KTahsil) ..................................................(e) Police !tation....................................................

(f) Re9enue DemarcationKHudbast =o. ...................

2. Bocation o* >actoryKEstablishment G

(a)

!tate.................................................

..

(b)

District.............................................

..

(c)

?unicipalityKFard..........................

.....

%. (a) Fhether the buildingKpremises o*

*actoryKestablishment is oned or

hired

G .................................................................................

(b) I* hired or there is a change in thename o* unitKonership# please

indicateG/

(i) E!I Code =o.# i* co9ered

earlier .................................................................................

(ii) Date *rom hich earlier*actoryK establishment closeddon

.................................................................................

(iii) Terms and conditions underhich property

acuiredKta8en on lease

.................................................................................
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47/102

DeedKResolution)

(b) "i9e name# present and permanentresidential address o* presentProprietorK?anaging Directors#

DirectorK?anaging Partners#

PartnersK!ecretary o* the Co

operati9e !ociety.

=ame Designation Address

(i)

(ii)

(iii)

(i')

(')

('i)

('ii)

14.

Address(es) o* the Registered7**iceKHead 7**iceK ranch 7**iceK!ales

7**iceKAdministrati9e 7**iceK other

o**ices# i* any# ith number o*

employees attached ith each such

o**ice and person responsible *or the

o**ice

G Addressas on

date

=o. o*employee

Phone=o.K >a

=o.

>unction Personresponsible

*or dayto

day

*unctioning

o* the o**ice

("i9e details on a separate sheet# i* reuired)12

.

(a) Fhether any or8Kbusiness carried

out through contractorKimmediate

employer

G .................................................................................

(b) I* yes# gi9e nature o* suchor8Kbusiness

G .................................................................................

1%

.

(a) EP> Code =o. G =o. Issuing Authority

(I* co9ered under EP> Act)

1. Total number o* employees employed *or ages directly and through immediate employers

on the date o* application (Fhether manualKclericalKsuper9isor# connected ith the administration

or purchase o* ra materials or distribution or sale o* productKser9ice# hether permanent ortemporary)

As on date Total =o. o* employees =o. o* employees draing

ages Rs %&& or less

?ale >emale Total ?ale >emale Total

Employed directly by the Principal

Employer

Through Immediate employerK

Contractor

Total

1. Total ages paid in the preceding month Total ages Fages paid to

employees draing

ages Rs %&& or

less

To employees employed directly by the

Principal employer

To employees employed through immediate


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employerKContractor

13. "i9e *irst date since hen 1&K'&;; or more

co9erable employees under E!I Act ere

employed *or ages

................................................................................

I hereby declare that the statement gi9en abo9e is correct to the best o* my 8noledge and belie*. I

also underta8e to intimate changes# i* any# promptly to the Regional 7**iceK!ubRegional 7**ice.

E!I Corporation is soon as such changes ta8e place

D$' =ame and !ignature.....................................

Place Designation ith seal............................................

:!hould be signed by principal employer uKs. '(1)o* E!I ActactoriesAct# 1$23# the person so named5

(b) In any establishment under the control o* any department o* any "o9ernment# in

India the authority appointed by such "o9ernment in this behal* or here no

authority is so appointed# the head o* the Department5

(c) In any other establishment# any person responsible *or the super9ision and control o*

the establishment.

=ote ;2/S7ccupierS o* a *actoryKestablishment means the person ho has ultimate

control o9er the a**airs o* the *actoryKestablishment and hen the said a**airs areentrusted to a managing agent shall be the occupier o* the *actoryKestablishment

=ote ./SEmployeesS means any person employed *or ages in or in connection iththe or8 o* a *actory or an establishment to hich this Act applies# and

(i) ho is directly employed by the principal employer on any or8 o*# or incidental or

preliminary to or connected ith the or8 o*# the *actory or establishment hether

such or8 is done by the employee in the *actory or establishment or elsehere5 or

(ii) ho is employed by or through an immediate employer on the premises o* the

*actory or establishment or under the super9ision o* the principal employer or hisagent on or8 hich is ordinarily part o* the or8 o* the *actory or establishment or

hich is preliminary to be carried on in or incidental to the purpose o* the *actory or

establishment5 or

(iii) hose ser9ices are temporarily lent or let on hire to the principal employer by theperson ith hom the person hose ser9ices are so lent or let on hire has entered

into a contact o* ser9ice5

and includes any person employed *or ages on any or8 connected ith the

administration o* the *actory or establishment or any part department or branch thereo*

ith the purchase o* ra materials *or# or the distribution or sale o* the products o*# the*actory or establishment5 :or any person engaged as an apprentice# not being an

apprentice engaged under the Apprentices Act# 1$1 (%' o* 1$1)# or under the standing


50/102

orders o* the establishment# but does not includeorce5 or

(b) Any person so employed hose ages ecluding remuneration *or o9ertime or8eceeds such ages as may be prescribed by the Central "o9ernment# a monthG

Pro9ided that an employee hose ages ecluding remuneration *or o9ertime or8eceeds such ages as may be prescribed by the Central "o9ernment# a month at any

time a*ter and not be*ore the beginning o* the contribution period# shall continue to be anemployee until the end o* that period.

=ote 2/SFagesS means all remuneration paid or payable in cash to an employee# i* theterms o* the contract o* employment# epress or implied# ere *ul*illed and includes any

payment to an employee in respect o* any period o* authoriLed lea9e# loc8out# stri8e

hich is not illegal or layo** and other additional remuneration# i* any# paid at inter9alsnot eceeding to months# but does not includeG

(a) any contribution paid by the employer to any pension *und or pro9ident *und# orunder this Act5

(b) any tra9elling alloance or the 9alue o* any tra9elling concession5

(c) any sum paid to the person employed to de*ray special epenses entailed on him bythe nature o* his employment5 or

(d) any gratuity payable on discharge.


51/102

'2a>7R?&1(A)

>7R? 7> A==+AB I=>7R?ATI7= 7= >ACT7RK

E!TABI!H?E=T C76ERED +=DER E!I ACT

(Regulation 1&C)

;EmployerQs Code =o.

1. =ame o* the >actoryKEstablishment G.

'. Complete postal address o* the

>actoryK Establishment

G

.PI=.

4. (a) Telephone =o.# i* any (b) >a =o. i*any.

(c) Email address# i* any

(d) =ame o* TonKRe9enue 6illage (Talu8KTahsil)

(e) Police !tation

(f) Re9enue DemarcationKHudbast =o2. Bocation o* >actoryKEstablishment G(a) !tate..

(b) District

(c) ?unicipality K Fard

%. (a)Details o* an8 AKcG G(b) =ame o* an8 and ranch

(a) Account =o (i)..

(b) Account =o (ii)....

(c) Account =o (iii)..

.(a) Income Ta PA=K"IR =o. G

(b) Income Ta FardKCircleKArea ..

. (a)In case o* *actory hether licence

issued under section '(m)(i) or

'(m)(ii) o* the >actories Act#

1$23

G...

(b) Poer Connection =o. =o. !anctioned poer load Issuing Authority

3. (a)Fhether it is Public or Pri9ate Btd.

CompanyKPartnershipKProprietorshi

pKCooperati9e !ocietyK7nership

(Attach copy o* ?emorandum

and Articles o*

AssociationKPartnershipDeedKResolution)

G...

(b) "i9e name# present and permanent

residential address o* present

ProprietorK ?anaging Directors#

DirectorK?anaging Partners#

PartnersK!ecretary o* the Co

operati9e !ociety

=ame Designation Address

(i) (ii) (iii) (i') (')
http://www.taxmann.net/Sm2006/SMRules/ftn24a_439.htmhttp://www.taxmann.net/Sm2006/SMRules/ftn24a_439.htm


52/102

('i) ('ii)

$. Address(es) o* the Registered

7**iceKHead 7**iceKranch

7**iceK!ales 7**iceKAdministrati9e7**iceKother o**ices# i* any# ith

number o* employees attached ith

each such o**ice and person

responsible *or the o**ice

Address ason date

=o. o*

employee

Phone

=o.K>a =o.

>unction Person

responsible *or

daytoday*unctioning o*

the o**ice

"i9e details on a separate sheet# i* reuired)1&.(a) Fhether any or8Kbusiness

carried out through

contractorKimmediate employer

G..

(b)I* yes# gi9e nature o* such

or8Kbusiness

G..

I hereby declare that the statement gi9en abo9e is correct to the best o* my 8noledge and belie*. I also

underta8e to intimate changes# i* any# promptly to the Regional 7**iceK!ubRegional 7**ice# E!I Corporation

as soon as such changes ta8e placeDate =ame and !ignature

Place Designation ith seal.

:!hould be signed by principal employer uKs. '(1) o* E!I ActatherQsKHusbandQs name 11. =ame and Address o* the Employer

2. Date o* birth Day ?onth ear %.

?arital

!tatus

?K+KF

. !e ?K>

. Present Address 3. Permanent Address 1'. In case o* any pre9ious employment please *ill up thedetails as underG

. . (a) Pre9ious Ins. =o.

. . (b) EmployerQs Code =o.

. . (c)=ame and Address o* Employer

Pin code Pin code

Telephone =o.Kemail address Telephone =o.Kemail address

ranch 7**ice Dispensary Telephone =o.Kemail address

(C). Details o* =ominee uKs. 1 o* E!I Act 1$23KRule %(') o* E!I (Central) Rules# 1$%& *or payment o* cash bene*it in the e9ent o*death


54/102

=ame Relationship Address

I hereby declare that the particulars gi9en by me are correct to the best o* my 8noledge and belie*. I underta8e to intimate theCorporation any changes in the membership o* my *amily ithin 1% days o* such change.

Countersignature by the employer !ignatureKT.I# o* IP

!ignature ith seal

(D) >A?IB PARTIC+BAR! 7> I=!+RED PER!7=

!l.=o.

=ame Date o* irthKAge as on date o**illing *orm

Relationship ith theEmployee

Fhether residing ithhimKher. !ay

I* Q=oQ !tate place o*Residence

es =o Ton !tate

1.

'.

4.

2.

%.

.

.

E!I Corporation Temporary Identity Card 6alid *or 4 months *orm the date o* appointment

=ame (!pace *or photograph)

Ins. =o. Date o* appointment

ranch 7**ice Dispensary


55/102

EmployeeQs Code =o. and Address

6alidity !ignatureKT.I o* I.P. !ignature o* .?. ithseal

DatedG

I=!TR+CTI7=!

1. !ubmission o* >orm1 is go9erned by Regulations 11 and 1' o* E!I ("eneral) Regulations# 1$%&.

'. S>amilyS means all or any o* the *olloing relati9es o* an Insured Person# namelyG

(i) a spouse5 (ii) a minor legitimate or adopted child dependant upon the I.P.5 !iii# a child ho is #holly dependant on the earnings

o* the I.P. and ho is (a) recei9ing education# till he or she attains the age o* '1 years (b) an unmarried daughter5 (i9) a child hois in*irm by reason o* any physical or mental abnormality or in@ury and is holly dependant on the earnings o* the I.P. so long as

the in*irmity continues5 (9) dependant parents (Please see !ection ' Clause 11 o* the E!I Act# 1$23 *or details).

4. Identity Card is notTrans*erable.

2. Boss o* Identity Card be reported to EmployerKranch ?anager immediately.

%. !ubmission o* *alse in*ormation attracts penal action under !ection 32 o* E!I Act# 1$23.

. This *orm duly *illed in must reach the concerned ranch 7**ice ithin 1& days o* appointment o* an Employee. Delay attracts

penal action under !ection 3% o* the Act against employer.

. As an insured person you and your dependent *amily members are entitled to *ull medical care *rom today itsel*. The other bene*its

in cash include (a) !ic8ness ene*it (') Temporary Disablement bene*it (4) Permanent disablement bene*it (2) Dependents bene*it and(%) ?aternity bene*it (in case o* omen employees) sub@ect to *ul*illment o* contributory conditions.

3. >or more details please contact ebsite o* E!IC at .esic.org.in or contact Regional 7**ice or ranch 7**ice.

>7R RA=CH 7>>ICE +!E 7=B

1. Date o* allotment o* Ins. =o.G..

Date o* issue o* T.I.C. G G..


56/102

4. =ameK=o# o* Disp. G G..

2. Fhether reciprocal medical arrangements in9ol9ed. I* yes# please indicateG G..

!ignature o* ranch ?anager

!l.

=o.

=ame Date o* irthKAge as on date o*

*iling *orm

Relationship ith the

Employee

Fhether residing ith

himKher. !ay

I* Q=oQ !tate place o*

Residence

es =o Ton !tate

1.

'.

4.

2.

%.

.

.


57/102

'3[:ORM 1A

:3e&ulation 18A

:3e&ulation 1"orms ....................................................................................................................................................

Continuationsheets .....................................................................................................................................

............
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60/102

4::ORM 4

:3e&ulations 17 D 98A E=TR>ATHER 7R H+!A=D! =A?E B7CAB 7>>ICE

PRE!E=T ADDRE!! DI!PE=!AR

IDE=TI>ICATI7= ?AR-!

E?PB7?E=T CHA="E!

DATE C7DE =7. DATE C7DE =7.

PARTIC+BAR! 7> ?E?ER! 7> >A?IB!.

=7.

=A?E DATE

7>IRTH

REBATI7=!HIP

FITH I.P.

IDE=TI>ICATI7=

?AR-!

ATTE!TATI7=

I.?.7.KI.?.P.

!ignature or Thumb Issued byor CP ending 4&th !eptember# due date is 11th =o9ember

E3A=$E $33AI=

EmployerQs =ame and Address

EmployerQs Code =o.. Period

*rom. to.

!I.=o.

Insurance

=umber

=ame o*Insured

person

=o. o* days*or hich

ages paid

Total amounto* ages paid

(Rs)

EmployeeQscontribution

deducted (Rs)

A9erageDaily

Fages (Rs)

Fhetherstill

continues

or8ing

Remar8

1 ' 4 2 % 3 $


64/102

T7TAB

;Date o* appointment and lea9ing the @ob may be gi9en in remar8s column

!ignature o* the Employer

(>7R 7>>ICIAB +!E)

1. Entitlement position mar8ed.

'. Total o* Col. % o* Return chec8ed and *ound correctK

correct amount is indicated.

4. Chec8ed the amount o* EmployerQsKEmployeeQs

contribution paid hich is in orderKobser9ation memoenclosed.

Countersignat

ure

..

>252$2 Gead $ler% ranch fficer


65/102


66/102

212'RE". >7R?

3e&ister of Employees

E?PB7EE!Q !TATE I=!+RA=CE C7RP7RATI7=

(Regulation 4')Contribution Period G >rom to.

?onth..

!

I.

=o

.

Insura

nce

=o.

=a

me

o*the

Insu

redPers

on

;=am

e o*

dispensary to

hich

attached

7ccupat

ion

Depart

ment

andshi*t# i*

any

I* appointed

or le*t ser9ice

during thecontribution

period# date

o*appointmentKl

ea9ing

ser9ice

=o.

o*

days*or

hi

chag

es

paid

Kpay

able

Total

amount

o*ages

paidKpa

yable

Employ

eesQ

share o*contribu

tion

1 ' 4 4(A) 2 % 3 $

Total

EmployerQs share

"ranttotal

Paid on

?onth .. ?onth .. ?onth ..

=o. o* days

*or hich

agespaidKpayab

le

Total

amount o*

agespaidK

payable

(Rs)

EmployeesQ

share o*

contribution (Rs)

=o. o* days

*or hich

agespaidKpayab

le

Total

amount o*

agespaidK

payable

(Rs)

EmployeesQ

share o*

contribution (Rs)

=o. o* days

*or hich

agespaidKpayab

le

Total

amount o*

agespaidK

payable

(Rs)

Employee

share o*

contributn (Rs)

1& 11 1' 14 12 1% 1 1 13

Total Total Total

EmployersQ

share

EmployersQ

share

EmployersQ

share

"rand "rand "rand


67/102

Total Total Total

Paid on Paid on Paid on

?onth

..

?onth

..

!ummary ..

=o. o*

days *or

hich

ages

paidKpay

able

Total

amount

o*

ages

paidK

payable

(Rs)

Employe

esQ share

o*

contribut

ion (Rs)

=o. o*

days *or

hich

ages

paidKpay

able

Total

amount

o*

ages

paidK

payable

(Rs)

Employe

esQ share

o*

contribut

ion (Rs)

Total

=o. o*

days *or

hich

ages

paidKpay

able inContribu

tion

period

Total

amount

o* ages

paidK

payable

in

Contribution

period

(Rs)

Total

Employe

esQ share

o*

Contribu

tion in

Contribution

period

(Rs)

Dail

y

Fa

ge

('%

')

(Rs.)

1$ '& '1 '' '4 '2 '% ' ' '3

Total Total Employe

rsQ share Employe

rsQ share

"rand

Total "rand

Total

Paid on Paid on =ote2/ The *igures in Columns to '2 shall be in respect o* age periods ending in a

particular calendar month.


68/102

242RE". >7R?

(Con*idential)

(Deposit this certi*icate ithin 4 days ith the appropriate ranch 7**ice to a9oid

possible loss o* bene*it under Regulation 2)/irstBIntermediateB/inal $ertificate

EmployeesQ !tate Insurance Corporation

(Regulations %# %3# %$)

oo8 =o.. ..

!erial =o. !tamp o* Dispensary !ignature or Thumb impression o*the I.P.

Date o* >irst Certi*icate o*spell o* !ic8ness or

Disablement

.

EmployerQs Code=o.

ranch

7**ice.=ame..sKKd.Ins.

=o..

Certi*ied that I ha9e eamined you today and that in my opinionG/

Any other remar8s

by the ?edical

7**icer

(i); ou no need medical treatment# attendance and abstention

*rom or8 on medical grounds by reason o* (diagnosis)

. (ii); ou ha9e continued to need medical treatment# attendance

and abstention *rom or8 on medical grounds up to andincluding this day by reason o* (diagnosis)

...

.

. (iii); In my opinion you ill be *it to resume or8tomorroKon

Attested by ?edical

7**icer

=ote2/The date o* *itness must in no case be later than the third day a*ter the date o* the

eamination in case o* >irst and >inal Certi*icate

Date.. !ignature

Insurance ?edical 7**icer Rubber stamp

=ame in loc8 Betters.; !tri8e out hiche9er is not applicable

Important*/

1. Any person ho ma8es *alse statement or representation *or the purpose o*obtaining bene*it hether *or himsel*Ksome other person shall be punishable ith

imprisonment up to months or *ine up to Rs '&&& or both.


69/102

'. This *orm should be completed and submitted ithout delay to the appropriate

ranch 7**ice to escape penal deduction o* bene*it under Regulation 2 read ith

Regulation $$ o* E!I ("eneral) Regulations# 1$%&.

4. Insured person must sign# ith date# the claim *orm to a9oid delay andincon9enience.


70/102

232$RE". >7R?3

(Con*idential)

(Deposit this certi*icate ithin 4 days ith the appropriate ranch 7**ice to a9oid

possible loss o* bene*it under Regulation 2)Special Intermediate $ertificate


(Regulations 1 and 3$)

oo8 =o.. ..

!erial =o. !tamp o* Dispensary !ignature or Thumb impression o*

the I.P.

Date o* >irst Certi*icate o*

spell o* !ic8ness orDisablement

.

EmployerQs Code

=o.

ranch

7**ice.To..sKKd.Ins.

=o..

Any other remar8s by

the ?edical 7**icer

Certi*ied that I ha9e eamined you

.. today and that in my opinion

you ha9e continued to need medical treatment and ha9e

remained incapable to or8 up to and including this day byreason o*.I *urther certi*y that by

@udging your present condition it is *ound that your sic8ness is

o* such a character that it ill be unnecessary to see you *or thepurpose o* treatment more *reuently than once in

ee8s# and you ill reuire medical

treatment and ill remain incapable to or8 at least up to theend o*.ee8s *rom this dateI

propose to issue certi*icates in this *orm at the inter9al stated

abo9e# so long as your condition does not reuire more *reuentattendance. In my opinion you should noKneed not be re*erred

to a ?edical oard to determine i* you are permanently

disabled

..

..

..

Attestation by ?edical

7**icer

Date.. !ignature

Insurance ?edical 7**icer ith rubber stamp =ame inbloc8

letters


71/102

%RE". >7R?$

$laim for Sic%nessB2522B


72/102


73/102

(b) HeK!he remained on holidays ith ages *rom .........................

to .............................

(c) HeK!he as on ee8ly o** ith ages

*or .................................................................

(d) HeK!he as on layo** ith ages *rom ..........................

to ...................................

(e) HeK!he as on stri8e *rom .................................. to ...............................

'. In case# the IPKIF is paid any ages *or any o* the days *alling during the

abo9ementioned period subseuently# the same ill be noti*ied to you in due course.

4. The day proceeding the *irst day o* absence as;Kas not a holiday *or the Insured

PersonKInsured Foman.

DateG..................... !ignature ........................

=ame in bloc8 letter and

designation ....................................

Code =o. ....................................; !tri8e out i* not applicable


74/102


75/102

m

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o

y

ee

CNDTP

1'42%3$1

&

1

1

1

'

1

4

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ha

t

e

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ly

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e

in

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em

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76/102

p

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77/102

o

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s

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ot

ice

o

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8

121%1113


78/102

%31RE". >7R?1'

Accident 3eport from Employer


(Regulation 3)1. =ame and Address o*>actoryKEstablishment and Telephone =o.

'. =ature o* Industry or business

4. EmployerQs Code =o. 2. ranch 7**ice

%. =ame and address o*

in@ured person

. !e and Age . 7ccupation

3. Insurance =o. $. Department

1&. !hi*tKHrs. o* or8 on thedate o* accident

11. Hour at hich hestarted or8 on the day o*

accident

1'. Date and hour o* accident 14. Eact place o* accident

12. =ature and etent o*

in@ury (e.g. *atal# loss o*

*inger# *racture o* leg# scaldetc.)

1%. Bocation o* in@ury

(right leg# le*t hand or le*t

eye etc.)

1. Address o* premises

here accident happened

1. Date o* death in case

the in@ured person dies

13. In case the accident happened hile meeting an emergency# please stateG/

(i) Its nature / (ii) Fhether the in@ured

person# at the time o* theaccident as employed *or

the purpose o* his

employerQs trade or

business in or about thepremises at hich the

accident too8 place/

1$. DispensaryKI?P allotted

to in@ured person

'&. Dr or Dispensary or

Hospital *rom herein@ured person recei9ed or

is recei9ing treatment

'1. =ame and Address o*itnessG/

1.

'.


79/102

es =o

''. Fhether ages in *ull or part are payable to him *or the day o*

accident

'4. Fhether the in@ured person as an employee under section '($) o*

the Act on the day o* accident

'2. Fhether contribution as payable by him *or the day on hich

accident occurred

'%. Cause o* accident/

(a) !tate eactly hat the in@ured person as doing at the time o*

accident i.e. brie* description o* ho the accident occurred.

(b) Fas the in@ured person# at the time o* accident# acting in

contra9ention o*/

es =o

(1) the pro9ision o* any la applicable to him

or.

or

(') any orders gi9en by or on behal* o* his employer

or

or

(4) acting ithout instructions *rom hisemployer..

(c) In case reply to b(1)# (') or (4) is es# state hether the act as

done *or the purpose o* and in connection ith the employerQs trade or

business

'. In case the accident happened hile tra9elling in the

employerQs transport# state hether the in@ured person as

tra9ellingG/

(1) as a passenger to or *rom his place o* or8

(') ith the epress or implied permission o* his employer

(4) the transport is being operated by or on behal* o* the employer or

some other person by hom it is pro9ided in pursuance o*

arrangement made ith the employer# and

(2) the 9ehicle as beingKnot being operated in the ordinary course o*

public transport ser9ice

I certi*y that to the best o* my 8noledge and belie*# the abo9e particulars are correct in

e9ery respect

Date o* dispatch o*

report

!ignature o* the Employer.

=ame in bloc8 letters.

Designation


80/102

(ith !tamp)

(>or 7**icial +se)

Diary =o. o* accident register and date!ignature o*

.?.=ote2+Accident Report is reuired to be submitted to the appropriate ranch 7**ice as

ell as to Insurance ?edical 7**icerKI.?.P. ithin '2 hours o* the receipt o* notice o*

in@ury. In case o* *atal or serious accidents# it must be submitted immediately to a9oidlegal penal action under section 3%.


81/102

'RE". >7R?14

(In Duplicate);

5eath $ertificate

(>or DependantQs ene*it or >uneral Epenses)EmployeesQ !tate Insurance Corporation

(Regulations $ and $%C)

oo8 =o. !tamp o*

Dispensary

S12

=oHHHHHHHH

=ame o* the deceased Insured

Person...sKKd o*

.. Insurance

=o.I certi*y that in my opinion the abo9e named deceased Insured Person died ontheday o*

as a result o* an in@uryKdue to; I ;;had been

attending himKher *or pro9iding medical

bene*it be*ore hisKher death and I attended himKher *or the last time on

theday o*

!ignature

Insurance ?edical 7**icerKI.?.P.

=ame in bloc8 letters and rubber stamp

Any other remar8s by the ?edical7**icer

DatedG

;Please indicate the name o* the disease

;; ?ay be suitably amended i* the Insurance ?edical 7**icerKI.?.P. has not attended the

deceased person be*ore hisKher death


82/102

'RE". >7R?12

$laim for ermanent 5isablement enefit


(Regulation A)I ..sKKd

.. Insurance =o. . ha9ing been

declared as permanently disabled by the ?edical oardK?edical Appeal TribunalKEmployeesQ Insurance Court# claim Permanent Disablement ene*it accordingly *or the

period *rom .. to ..

The amount due may be paid to me by money orderKin cash at ranch 7**ice

..

!ignature or thumb impression o* the Claimant

=ame in bloc8 letters ..

and Address ...

..

Dated ..

Important* Any person ho ma8es a *alse statement or representation *or the purpose o*obtaining bene*it# hether *or himsel* or *or some other person# commits an

o**ence punishable ith imprisonment *or a term hich may etend up to si

months or ith a *ine up to Rs '&& or ith both


83/102

4RE". >7R?1%

$laim /orm for 5ependant?s enefit

E2&"3''. S$$' I.#' C"#2"#$%"(Regulation 3&)

=ame o* the deceased Insured Person ..Ins. =o!KFKD o*

.Date o* Death

.Bast employed as .. by

.

IKFe the *olloing# being dependants o* the abo9e named deceased Insured Person#hereby claim and accordingly apply *or dependantQs bene*it on account o* hisKher deathG

=ame o*

thedependant

!e Age or

year o*birth

?arital

status

Relationship

ith thedeceased

Present

Address

=ame o*

guardian in caseo* minor

1 ' 4 2 %

IKFe declare that the particulars gi9en abo9e are true to the best o* myKour 8noledge

and belie*

IKFe also declare that to the best o* myKour 8noledge and belie*# there is no other

dependant entitled to claim DependantQs ene*it in rKo the death o* the abo9e noteddeceased I.P.# sa9e and ecept those mentioned abo9e

Si&nature

1.

'.

4.

2.

AESAI=

Certi*ied that the declarations# as made abo9e# are true to the best o* my 8noledge andbelie*

=ame in bloc8 letters and

Rubber !tamp or !eal o* the

Attesting Authority

!ignature

Designation


84/102

; All ma@or dependants should sign indi9idually and the guardian to sign in case o* a

minor dependant

;; This certi*icate is to be gi9en by (i) an o**icer o* the Re9enue# ,udicial or ?agisterial

Departments o* "o9ernment# or (ii) a ?unicipal Commissioner# or (iii) a For8menQsCompensation Commissioner# or (i') the Head o* the "ram Panchayat under the

o**icial seal o* the Panchayat# or (') ?.B.A.K?.P.# ('i) "aLetted 7**icer# or ('ii) amember o* Bocal CommitteeKRegional oard o* the E!I Corporation# or ('iii) any

other authority considered appropriate by the ranch ?anager.

Important* Any person ho ma8es a *alse statement or representation *or the purpose o*obtaining bene*it# hether *or himsel* or *or some other person# commits an

o**ence punishable ith imprisonment *or a term hich may etend up to si

months or ith a *ine up to Rs '&& or ith both


85/102

2RE". >7R?1

$laim for eriodical ayments of 5ependants? enefit

Employees? State Insurance $orporation

(Regulation 34A)=ame o* the deceased Insured Person .Ins. =o

.I . being the

o* the abo9e named deceased InsuredPerson and also being hisKher dependant# do hereby claim DependantsQ ene*it *or the

period *rom .. to ..

The amount due may be paid to

me

by money order

In cashKby cheue at

ranch 7**ice

I also declare that/

;(i) I ha9e not married;Kremarried# so *ar

(Applicable only in case o* a *emale dependant)

;(ii) I ha9e not attained the age o* 13 years

(Applicable in case o* minor maleK*emale dependant)

;(iii) I am still in*irm

(Applicable only in case o* a legitimateKadopted; in*irm son or a

legitimateKadopted; unmarried in*irm daughter ho has attained 13 years o* age.

The claim to be accompanied# i* reuired# by a certi*icate o* speci*ied authority)

Date . ;;!ignature or Thumb impression o* the

Claimant

Present Address

.

=ame in bloc8 letters o*ClaimantK"uardian

or

;;;!ignatureKThumb impression o* the"uardian

*or ..

(=ame o* the minor Dependant)

through .(=ame o* the "uardian)..

hisKher .

(Relationship ith the ?inor)

; Please stri8e out hiche9er is not applicable

;; Applicable in the case o* a claim by a ma@or dependant


86/102

;;; Applicable in the case o* a claim *or a minor dependant

:Please re*er to Rule %3 o* the E!I (Central) Rules# 1$%&7R?1$

$laim for


90/102

1RE". >7R?'&

$laim for


91/102

AttestingAuthority; !tri8e out this line i* not applicable

;; Delete either (i) or (ii)# as may not be applicable in the case

;;; This certi*icate is to be gi9en by (i) an o**icer o* the Re9enue# ,udicial or ?agisterialDepartment5 or (ii) a ?unicipal Commissioner# or (iii) a For8menQs Compensation

Commissioner5 or (i') the Head o* "ram Panchayat under the o**icial seal o* the

Panchayat# or ?.B.A.K?.P.5 or (') a "aLetted 7**icer o* the CentralK!tate

"o9ernmentK?ember o* the Bocal CommitteeKRegional oard5 or ('i) any other authorityconsidered as appropriate by the ranch ?anager concerned

Important* 1. This claim *orm# duly *illed up# is reuired to be submitted to the

appropriate ranch 7**ice# together ith a death certi*icate in >orm '2#

ithin 4& days o* the death o* the Insured Foman

'. Any person ho ma8es a *alse statement or representation *or the purpose

o* obtaining bene*it# hether *or himsel* or *or some other person#

commits an o**ence punishable ith imprisonment *or a term hich mayetend up to si months or ith a *ine up to Rs '&&& or ith both


92/102

1aRE". >7R?'1

5eath $ertificate in case of $onfinement for $laimin&


93/102

(') The language may be suitably amended i* the Insurance ?edical

7**icerKInsurance ?edical Practitioner had not attended the deceased person

be*ore herKher childQs death


94/102

4RE". >7R?''

/uneral Expenses $laim /orm


(Regulation $%E)

Claim arising out o* death on .. o*

. sKKd o*

. aged. years# ha9ing Insurance =o.. . and last

employed as ..

. by ?Ks.. Code =o.

. I .. sKKd o*

.. aged... years declareG/

;(i) that I am the eldest sur9i9ing member o* the *amily o* the deceased Insured Person#

hose particulars are *urnished hereinabo9e# and that I actually incurred anependiture o* Rs .. (Rupees

only) necessary *or the *uneral

o* the said deceased person

or

;(ii) that the deceased Insured Person# hose particulars are *urnished thereinabo9e# didnot ha9e a *amilyKas not li9ing ith hisKher *amily at the time o* hisKher death and

that I actually incurred an ependiture o* Rs (Rupees .. only) on the

*uneral o* the deceased Insured Person

Accordingly# I do hereby claim *uneral epenses *or the amount o* Rs

.. (Rupees. only)

Date..

=ameinbloc8

letters

!ignatureKThumb impression o* the Claiman

ATTE!TATI7=

;;Certi*ied that the declarations# as made hereinabo9e# are true to the best o* my

8noledge and belie*


95/102

=ame in

bloc8

letters and

Rubber!tamp or

!eal o*the

Attesting

Authority

!ignature ith date

Designation....

Date

; Delete either (i) or (ii)# hich may not be applicable in the case

;; This certi*icate is to be gi9en by ( i) an o**icer o* the Re9enue# ,udicial or ?agisterial

Department5 or (ii) a ?unicipal Commissioner5 or (iii) a For8menQs CompensationCommissioner5 or (i') the Head o* "ram Panchayat under the o**icial seal o* the

Panchayat# or ?.B.AK?.P.5 or (') a "aLetted 7**icer o* the CentralK!tate "o9ernment#Bocal CommitteeKRegional oard5 or ('i) any other authority considered as appropriateby the ranch ?anager concerned

Important* Any person ho ma8es a *alse statement or representation *or the purpose o*

obtaining bene*it# hether *or himsel* or *or some other person# commits an o**ence

punishable ith imprisonment *or a term hich may etend up to si months or ith a

*ine up to Rs '&&& or ith both

=ote* In the case o* a minor# the guardian should sign the claim *orm on behal* o* theminor and then add the *olloing belo hisKher signatureG/

(=ame o* the ?inor)through

(=ame o* the

"uardian)

hisKher

(Relationship ith the

?inor)


96/102

2RE". >7R?'4

(To be submitted along ith claim o* ,une and December)

ife $ertificate for ermanent 5isablement enefit

E?PB7EE!Q !TATE I=!+RA=CE C7RP7RATI7=(Regulation 1&)

Insurance =o. o*

Permanently disabledperson

;Certi*ied that !hriK!mt KsKd o*

is ali9e this. day o*

. '& ...

!ignature ..

=ame in bloc8 letters o* signing Claimant

.

Designation ith Rubber!tampK!eal o* the

Attesting Authority

Date.

Important* Any person ho ma8es a *alse statement or representation *or the purpose o*

obtaining bene*it hether *or himsel* or *or some other person# commits an

o**ence punishable ith imprisonment *or a term hich may etend up to simonths or ith a *ine up to Rs '&&& or ith both

; This certi*icate is to be gi9en by (i) an o**icer o* the Re9enue# ,udicial or ?agisterialDepartment5 or (ii) a ?unicipal Commissioner5 or (iii) a For8menQs Compensation


Panchayat5 or (') ?.B.A.K?.P.5 or ('i) a "aLetted 7**icer o* the CentralK!tate"o9ernment5 or ('i) a member o* the Regional oardKBocal Committee o* the E!IC5 or

('iii) any other authority considered as appropriate by the ranch ?anager concerned


97/102

%RE". >7R?'2

(To be submitted along ith claim o* ,une and December)

5eclaration and $ertificate for 5ependant?s enefit

E?PB7EE!Q !TATE I=!+RA=CE C7RP7RATI7=(Regulation 1&A)

=ame o* the deceased Insured Person.. Ins. =o.

I # being the

..o* the abo9e named deceased Insured Person and alsobeing his dependant# do hereby solemnly declareG/

;(i) that I ha9e not marriedKremarried so *ar

(To be gi9en only by a *emale dependant)

;(ii) that I ha9e not yet attained the age o* eighteen years(To be gi9en only in respect o* a minor male or *emale dependant)

;(iii) that I ha9e attained the age o* eighteen years but continue to be in*irm

(To be gi9en by a legitimateKadopted in*irm son or by a legitimateKadopted in*irm

daughter. Certi*icate as speci*ied# to be attached# i* reuired)

Present AddressG

..

Date

!ignature or thumb impressiono* the dependant

or

=ame in bloc8 letters o* signing claimant

!ignature or thumb impression o*the

"uardian in case o* a minor

dependant

=ame o* the

minor..

Through.

(=ame o* the "uardian)

hisKher

(Relationship ith the ?inor)

CERTI>ICATE

;;Certi*ied that !hriK!mtK-umari .. KsKd o*


98/102

.. is ali9e this day# the.. day o*

'&. and that the declarations made abo9e are true to the best o* my

8noledge and belie*

Date

=ame in bloc8

letters and Rubber!tamp or !eal o* the

Attesting Authority

!ignature .

Designation.

; !tri8e out hiche9er is not applicable

;; This certi*icate is to be gi9en by ( i) an o**icer o* the Re9enue# ,udicial or ?agisterialDepartment5 or (ii) a ?unicipal Commissioner5 or (iii) a For8menQs Compensation


Panchayat5 or (') ?.B.A.K?.P.5 or ('i) a "aLetted 7**icer o* the CentralK!tate

"o9ernment5 or ('ii) a member o* the Regional oardKBocal Committee o* the E!IC5 or('iii) any other authority considered appropriate by the ranch ?anager concerned

Important* Any person ho ma8es a *alse statement or misrepresentation *or the purposeo* obtaining bene*it# hether *or himsel* or some other person# commits an

o**ence punishable ith imprisonment *or a term hich may etend up to simonths or ith a *ine up to Rs '&&& or ith both


99/102

SCHEDULE I

3:;;;7 O: EMPLOYEES

STATE INSURANCE (GENERAL) REGULATIONS, 1950

It is noti*ied *or general in*ormation that the Director"eneral under poers 9ested in

him by 9irtue o* the pro9isions o* regulation ' o* the Employees !tate Insurance

("eneral) Regulations# 1$% has speci*ied the *orm o* 0Certi*icate o* contributionspayable as per Anneure I o* this noti*ication.

> The employers ho ma8e payment o* contribution in time ill continue to submit thereturn o* contribution under regulation ' o* the Employees !tate Insurance ("eneral)

Regulations# 1$% as usual. Hoe9er# *rom the contribution period ending !eptember

1$$%# onards# those employers ho are unable to submit the a*oresaid return o*contribution due to nonpayment o* contribution (employers as ell as employees

share) to the Corporation ill be reuired to submit the 0certi*icate o* contributions

payable no speci*ied# ithin the same timelimit prescribed under regulation ' o* theEmployees !tate Insurance ("eneral) Regulations# 1$%&.

? The appropriate o**ice o* the Corporation ill start accepting the 0certi*icate o*contributions payable to be submitted by the de*aulting employers ithin the time

prescribed under regulation ' o* the Employees !tate Insurance ("eneral) Regulations#

1$% *rom the contribution period ending !eptember 1$$%# onards.

4 0The appropriate o**ice *or the purpose o* submission o* the said 0certi*icate o*contributions payable ill be the concerned regional o**ice as already noti*ied *or thepurpose o* submission o* return o* contribution under regulation ' o* the Employees

!tate Insurance ("eneral) Regulations# 1$%&.

5 In the *irst instance# the pro9isions o* this noti*ication ill come into *orce in the !tates

o* +ttar Pradesh# Haryana# Delhi# ?aharashtra# Pun@ab# Ra@asthan# -arnata8a and Fest

engal ith e**ect *rom the contribution period ending !eptember 1$$%# onards.


101/102

A==E+REI

CERTI:ICATE O: CONTRIUTIONS PAYALE

Employers Code =o. ...................

Employees !tate Insurance Corporation

$ertificate of contribution(Regulation ')

=ame and

address o* the

*actory orestablishment

..

...........................................................

Particulars o*

the principal

employer

(a)=ame ..

...........................................................(b)Designation ..

...........................................................

(c)Residentialaddress

.............................................................

period*rom......................................................................to...............................................................

I *urnish belo the details o* the employers and employees share o* contribution inrespect o* the under mentioned insured persons. I hereby declare that the details include

e9ery employee employed directly or through an immediate employer or in connection

ith the or8 o* the *actoryKestablishment or any or8 connected ith the administrationo* the *actoryKestablishment or purchase o* ra materials# sale or distribution o* *inished

products# etc.# to hom the contribution period to hich this certi*icate relates# applied

and that the contribution in respect o* employers and employees share has beencorrectly calculated and is payable in accordance ith the pro9isions o* the Act and

Regulations relating to the payment o* contributions.

Total contribution payable is amounting to Rs. .........comprising o* Rs. ............as

employers share and Rs. ................as employees share (Total o* column o* the

certi*icate).

1. I declare that the particulars gi9en abo9e are correct to the best o* my 8noledge and

belie*.

'. I declare that the *actoryKestablishment as co9ered under the Employees !tateInsurance Act during the contribution period to hich the abo9e in*ormation pertains.

Place G ........................... ..............................................

Date G .............................. !ignature

..............................................

Designation


102/102

Important instructions *

1. I* any I.P. is appointed *or the *irst time andKor lea9e ser9ice during the contribution

period# indicate OA..... or OB.... :date in the remar8s column (=o. 3)

Employees' State Insurance General Regulations 1950

Documents

Transcript of Employees' State Insurance General Regulations 1950