EMPLOYEES STATE INSURANCE (GENERAL) REGULATIONS, 1950 [RS/5/48, DATED 17-10-1950] In xrcis of th powrs confrrd by sction 97 of th Employs Stat Insuranc Act, 1948 (34 of 1948), th Employs Stat Insuranc Corporation is plasd to mak th following rgulations, th sam having bn prviously publishd as rquird by sub-sction (1) of th said sction, namly: CHAPTER I Short titl and xtnt. 1. (1) Ths rgulations may b calld th Employs Stat Insuranc (Gnral) Rgulations, 1950. (2) Thy xtnd to th whol of India including th Union Trritory of Pondichrry xcpt th Stat of Jammu and Kashmir. Dfinitions. 2. In ths rgulations, unlss th contxt othrwis rquirs (a) Act mans th Employs Stat Insuranc Act, 1948 (34 of 1948); (b) appointd day mans with rfrnc to any ara, factory or stablishmnt, th day from which th whol of Chaptrs IV and V of th Act apply to such ara, factory or stablishmnt, as th cas may b; (c) Appropriat Offic, Appropriat 1[Branch offic] or Appropriat Rgional Offic, shall man with rfrnc to any action takn undr ths rgulations, such offic of th Corporation as may b spcifid for that purpos undr a gnral or spcial ordr of th Corporation; (d) Cntral Ruls mans th ruls mad by th Cntral Govrnmnt undr sction 95 of th Act; () 1a[***] (f) 2[***] (g) Employr mans th principal mployr as dfind in th Act; (h) Employr s Cod Numbr mans th rgistration numbr allottd by th appropriat Rgional Offic to a factory or stablishmnt for th purposs of th Act, th ruls and ths rgulations; (i) Factory or Establishmnt mans a factory or an stablishmnt to which th Act applis; (j) Form mans a form appndd to ths rgulations; 3[(k) Idntity Card mans a prmannt idntity card issud by th appropriat offic to an insurd prson for idntification for th purposs of th Act, th Ruls and ths Rgulations;] (kk) Family Idntity Card mans a Card issud by th appropriat offic to an insurd prson for idntification of his family for th purposs of th Act, th ruls and ths rgulations; (l) Inspctor mans a prson appointd as such by th Corporation undr sction 45 of th Act; (m) Instructions mans instructions or ordrs issud by th Corporation or by such officr or officrs of th Corporation as may b authorisd by th Corporation in this bhalf; (n) Insuranc Mdical Officr mans a mdical practitionr appointd as such to provid mdical bnfit and to prform such othr functions as may b assignd to him and shall b dmd to b a duly appointd mdical practitionr for th purposs of Chaptr V of th Act; (o) Insuranc Numbr mans a numbr allottd by th appropriat offic to an mploy for th purposs of th Act, th ruls and ths rgulations;
(p) 3a[Branch offic] and Rgional Offic shall man, according to th contxt, such subordinat offic of th Corporation, st up at such plac and with such jurisdiction and functions as th Corporation may, from tim to tim dtrmin; (q) 3a[Branch] Managr mans a prson appointd by th Corporation as such 4[or] th officr-in-charg of a Local Offic; (r) Stat Ruls mans th ruls mad by a Stat Govrnmnt undr sction 96 of th Act; (s) Rgional Dirctor mans a prson appointd by th Corporation as such for a spcifid rgion; (t) Rgistrd Midwif mans a prson who is rgistrd as a midwif undr any law in forc in any Stat providing for rgistration of nurss and midwivs; (u) Ruls mans ruls mad by th Cntral or a Stat Govrnmnt undr th Act; (v) Spcifid mans spcifid by instructions issud from tim to tim by th Corporation or any authorisd officr; (w) Yar mans a calndar yar xcpt whn spcifically statd othrwis; (x) All othr words and xprssions hav th manings rspctivly assignd to thm in th Act or th ruls, as th cas may b. Th mannr in which th Corporation may xrcis its powrs. 3. (1) Whr a rgulation mpowrs th Corporation to spcify, prscrib, provid, dcid or dtrmin anything or to do any othr act, such powrs may b xrcisd by a rsolution of th Corporation or subjct to th provisions of sction 18 of th Act by a rsolution of th Standing Committ: Providd that th Corporation or th Standing Committ may dlgat any of powrs undr ths rgulations to a sub-committ or to such officrs of th Corporation as it may spcify in that bhalf: Providd furthr that no powr shall b dlgatd undr this rgulation which undr th Act is rquird to b xrcisd by th Corporation only. (2) Any appointmnt to b mad by th Corporation undr ths rgulations, shall b mad by th Dirctor-Gnral or by such othr officrs as may b authorisd in this bhalf by th Standing Committ. Exrcis of powrs by an offic. 3A. Whr a powr is to b xrcisd by th appropriat Offic or appropriat 3a[Branch offic] or appropriat Rgional Offic it shall b xrcisd by th officr for th tim bing in charg throf or by such othr officr as may b authorisd for th purpos undr gnral or spcial ordrs of th Dirctor-Gnral. 5[Contribution and bnfit priods. 4. Contribution priods and th corrsponding bnfit priods shall b as undr : Contribution priod 1st April to 30th Sptmbr 1st Octobr to 31st March of th yar following Corrsponding bnfit priod 1st January of th yar following to 30th Jun. 1st July to 31st Dcmbr: Providd that in th cas of a prson who bcoms an mploy within th maning of th Act for th first tim, th first contribution priod shall commnc from th dat of such mploymnt in th contribution priod currnt on that day and th corrsponding bnfit priod for him shall commnc on th xpiry of th priod of nin months from th dat of such mploymnt.] 5. 6[* * *]
Mtings of th Corporation, th Standing Committ and th Mdical Bnfit Council. 6. Th mtings of th Corporation, th Standing Committ and th Mdical Bnfit Council shall b hld in accordanc with th Cntral Ruls at such tim and plac as may b fixd by th Chairman concrnd. Dcision by majority. 7. Evry mattr coming up for dcision bfor a mting of th Corporation, th Standing Committ or th Mdical Bnfit Council shall b dcidd by a majority of prsons prsnt and voting at th tim of th mting and in cas of quality of vots th Chairman of th mting shall hav an additional casting vot. Mod of xrcising vot. 8. Th vots shall b takn by show of hands and th nams of prsons voting in favour and against any proposition shall b rcordd only if any mmbr prsnt rqusts th Chairman to do so. Mattrs to b brought bfor th Corporation. 9. In addition to th mattrs which ar, undr any spcific provision of th Act or th Cntral Ruls, rquird to b placd bfor th Corporation, th following mattrs shall b rfrrd to th Corporation for its dcision : (a) rgulations undr sction 97 and amndmnts thrto bfor final publication; (b) any masurs proposd undr sction 19 of th Act; (c) any proposal to xtnd mdical bnfit to familis undr sub-sction (2) of sction 46; (d) any disput proposd to b rfrrd to arbitration undr sub-sction (4) of sction 58; () any proposal to st up hospitals undr sction 59; (f) any proposal to grant xmption undr sction 91; (g) any proposal to nhanc bnfits undr sction 99; (h) any othr mattr which th corporation or its Chairman may dirct th Standing Committ or th Dirctor-Gnral to plac bfor th Corporation. 7[Rgional Boards. 10. (1) A Rgional Board may b st up for ach Stat or Union Trritory by th Chairman of th Corporation and shall consist of th following mmbrs, namly: (a) a Chairman to b nominatd by th Chairman of th Corporation in consultation with th Stat Govrnmnt or th Administration of th Union Trritory; (b) a Vic-Chairman to b nominatd by th Chairman of th Corporation in consultation with th Stat Govrnmnt or th Administration of th Union Trritory; (c) on rprsntativ of th Stat or th Union Trritory to b nominatd by th Stat Govrnmnt or th Administration of th Union Trritory; (d) (i) th Administrativ Mdical Officr or any othr Officr dirctly in charg of th Employs Stat Insuranc Schm in th Stat or th Union Trritory x officio; 8[(ii) th Rgional Dputy Mdical Commissionr of th Corporation x officio;] () on rprsntativ ach of th mployrs and mploys from th Stat or th Union Trritory to b nominatd by th Chairman of th Corporation in consultation with such organisations of th mployrs and th mploys as may b rcommndd for th purpos by th Stat Govrnmnt or th Union Trritory; (f) mmbrs of th Corporation othr than th Chairman and th Vic-Chairman and officials, if any, amongst thos nominatd by th Cntral Govrnmnt undr claus (c) of sction 4 of th Act, rsiding in th Stat or th Union Trritory x officio;
9[(g) mmbrs of th Mdical Bnfit Council nominatd by th Cntral Govrnmnt undr clauss (), (f) and (g) of sction 10 of th Act rsiding in th Stat or th Union Trritory x officio : 10[Providd that whr th Chairman of th Corporation so considrs it to b xpdint h may nominat such additional rprsntativs of mployrs, and mploys, not xcding thr from ach sid, with a viw to providing for th adquat rprsntation of important organisations not includd in th nominations of th Stat Govrnmnts, or th Union Trritory and to maintain th parity btwn th numbr of rprsntativ of such mployrs and mploys: Providd furthr that th Chairman of th Corporation shall nominat such additional rprsntativs of mployrs and mploys not xcding thr from ach sid whr th numbr of rprsntativs of mployrs and mploys including th x officio mmbrs, if lss than thr ach.] 11[(2) A Rgional Board may, if it considrs it dsirabl, co-opt th Officr in-charg of a Sub- Rgional Offic st up within its boundaris, and/or a mmbr of th mdical profssion in th Rgion and th prson(s) so co-optd shall continu to b mmbr(s) during th plasur of th Rgional Board.] (3) Th Rgional Dirctor or Officr-in-charg of th Rgional Offic shall b th mmbr scrtary of th Board. (4)(i) Sav as xprssly providd in this rgulation, th trm of offic of th mmbrs of th Rgional Board rfrrd to in 12[claus () of and th proviso to] sub-rgulation (1), shall b 13[thr yars] commncing from th dat on which thir nomination is notifid, providd that th mmbrs of th Rgional Board, shall, notwithstanding th xpiry of th said priod, continu to hold offic until th nomination of thir succssors is notifid. (ii) Sav as xprssly providd in this rgulation, th mmbrs of th Rgional Board rfrrd to in 14[claus (c)] of sub-rgulation (1) shall hold offic during th plasur of th Stat Govrnmnt nominating thm. (iii) A mmbr of th Rgional Board rfrrd to in 15[claus (f)] or sub-rgulation (1) shall cas to hold offic whn h cass to b a mmbr of th Corporation or cass to rsid in that ara. (iv) Any mmbr rfrrd to in claus (i) of this sub-rgulation nominatd to fill a casual vacancy shall hold offic for th rmaindr of th trm of offic of th mmbr in whos plac h is nominatd. (v) An outgoing mmbr shall b ligibl for rnomination. (5) A mmbr of th Rgional Board rfrrd to in 16[claus () of and th proviso to] subrgulation (1) abov, may rsign his offic by notic in writing to th Chairman of th Corporation, through th Chairman, Rgional Board, and his sat shall fall vacant on th accptanc of th rsignation. (6)(i) A mmbr of th Rgional Board rfrrd to in 16[claus () of and th proviso to] subrgulation (1) shall cas to b a mmbr of th Board if h fails to attnd thr conscutiv mtings throf providd that his mmbrship may b rstord by th Chairman of th Corporation on his bing satisfid as to th unavoidabl natur of th circumstancs which ld to his non-attndanc. (ii) Whn any prson nominatd to rprsnt an mployr s or mploy s organisation on th Rgional Board has casd to rprsnt such organisation, th Chairman of th Corporation, may, by notification in th Gaztt of India, dclar that such prson shall cas to b a mmbr throf with ffct from such dat as may b spcifid thrin. (7) Th mmbrs of th Rgional Board shall rciv such fs and allowancs as may b prscribd by th Cntral Govrnmnt for mmbrs of th Corporation. (8) A mmbr shall b disqualifid for bing nominatd or for bing a mmbr of th Rgional Board : (i) if h is dclard to b of unsound mind by a comptnt court ; or (ii) if h is an undischargd insolvnt; or (iii) if bfor or aftr th commncmnt of th Rgulations h has bn convictd of an offnc involving moral turpitud.
(9) Th Scrtary shall, with th approval of th Chairman, fix th dat, tim and plac of, and also draw up th Agnda for, vry mting. Notic of not lss than tn days from th dat of posting shall ordinarily b givn to vry mmbr for ach mting, providd that if it is ncssary to convn an mrgncy mting, a rasonabl notic throf shall b givn to vry mmbr. No mattr othr than that includd in th Agnda shall b considrd xcpt with th prmission of th Chairman. (10) No businss shall b transactd at any mting unlss thr is a quorum of not lss than on third of th numbr of th mmbrs on th Board, providd that if at any mting, sufficint numbr of mmbrs ar not prsnt to form a quorum, th Chairman may adjourn th mting to a dat not latr than svn days from th dat of original mting and it shall thrupon b lawful to dispos of th businss at such adjournd mting irrspctiv of th numbr of mmbrs prsnt. (11) All mattrs shall b dcidd by a majority of prsons prsnt and voting and in cas of quality of vots, th Chairman shall hav a casting vot or a scond vot. (12) Th Chairman or in his absnc th Vic-Chairman of th Rgional Board shall prsid at th mtings. In th vnt of th absnc of both th Chairman and th Vic-Chairman th mmbrs prsnt may lct on from amongst thmslvs to prsid. (13) (i) Th minuts of ach mting showing intr alia th nams of th mmbrs prsnt thrat shall b forwardd to all mmbrs of th Rgional Board as soon aftr th mting as possibl and in any cas not latr than fiftn days from th dat of th mting. (ii) Th rcords of th minuts of ach mting shall b signd by th Chairman aftr confirmation with such modifications as may b considrd ncssary at th mting, at which th minuts ar confirmd. 17[(14) A Rgional Board shall prform th following functions in rspct of th Rgion for which it is st up: (a) Such administrativ and/or xcutiv functions as may, from tim to tim b ntrustd or dlgatd to it by a rsolution, by th Corporation or th Standing Committ. (b) To mak rcommndations from tim to tim in rgard to changs which may in its opinion b advisabl in th Act, Ruls and Rgulations and forms and procdur to b followd in th running of th Schm. (c) To dcid within th broad framwork of th gnral dcisions and programm of prioritis of th Corporation, th following mattrs, providd that whr th spcific approval of th Corporation or th appropriat Govrnmnt is rquird, such approval shall b takn: (i) xtnsion of th Schm to othr catgoris of stablishmnts in accordanc with th ordr of prioritis laid down by th Corporation; (ii) xtnsion of Schm to nw aras and xtnsion of mdical car to familis; (iii) adoption of spcial masurs to mt pculiar conditions in th ara; (iv) improvmnt in bnfits; (v) provisions of indoor mdical tratmnt; (vi) masurs and arrangmnts for th rhabilitation of insurd prsons in th ara, who ar prmanntly disabld; (vii) scuring complianc by mployrs with th various provisions of th Employs Stat Insuranc Act, th Rgulations and othr Ruls and instructions; (d) To rviw from tim to tim th working of th Schm in th Stat both on th mdical sid as wll as cash bnfit sid and to advis th Corporation and th Stat Govrnmnt on masurs to improv th working of th Schm both in rgard to paymnt of cash bnfits and administration of mdical bnfit and in particular to promot prvntiv halth masurs, safty and prsonal hygin and to rviw and chck lax crtification and othr abuss of th Schm. () To look into gnral grivancs, complaints and difficultis of insurd prsons, mployrs, tc., as it may considr ncssary. (f) To advis th Corporation on such mattrs as may b rfrrd to it for advic by th Standing Committ or th Dirctor-Gnral.
Th Rgional Board may st up suitabl Sub-Committs for carrying out any of its functions and may sk th assistanc or advic of Local Committs whr ncssary.] (15)(i) If in th opinion of th Corporation, th Rgional Board prsistntly maks dfault in prforming th dutis imposd on it by or undr this rgulation or abuss its powrs, th Corporation may by notification in th Gaztt of India suprsd th Rgional Board. (ii) Upon th publication of a notification undr claus (i) abov suprsding th Rgional Board, all th mmbrs of th Rgional Board shall from th dat of such publication b dmd to hav vacatd thir offics. (iii) Whn th Rgional Board has bn suprsdd th Corporation may (a) immdiatly constitut a nw Rgional Board in accordanc with this rgulation; or (b) appoint such agncy for such priod as it may think fit to xrcis th powrs and prform th functions of th Rgional Board and such agncy shall b comptnt to xrcis all powrs and prform all th functions of th Rgional Board. 18[Local committs. 10A. (1) A local committ may b st up for such ara as may b considrd appropriat by th Rgional Board and shall consist of th following mmbrs, namly: (a) a Chairman to b nominatd by th Chairman, Rgional Board, who shall b an official of th Corporation or of th Stat in which th ara is situatd; (b) an official of th Stat to th nominatd by th Stat Govrnmnt; (c) th Administrativ Mdical Officr-in-charg of th Schm in th ara concrnd, x officio, or any othr mdical officr nominatd by him; (d) such numbr, to bing lss than two nor mor than four, of rprsntativs of mployrs in th ara as may b considrd appropriat by th Chairman, Rgional Board, to b nominatd by him, in consultation with such mployrs organisations as may b rcommndd for th purpos by th Stat Govrnmnt; () an qual numbr of rprsntativs of mploys in th ara to b nominatd by th Chairman, Rgional Board, in consultation with such organisations of mploys as may b rcommndd for th purpos by th Stat Govrnmnt; (f) an official of th Corporation to b nominatd by th Dirctor-Gnral, who shall also act as Scrtary to th Committ: Providd that whr th Chairman, Rgional Board, so considrs it to b xpdint, h may nominat such additional rprsntativs of mployrs and mploys, not xcding two from ach sid, with a viw to providing for th adquat rprsntation of important organisations not includd in th nominations of th Stat Govrnmnt and to maintaining th parity btwn th numbr of rprsntativs of such mployrs and mploys: Providd furthr that in any ara in which mdical car is providd through a panl systm, a local committ may co-opt a mmbr rprsnting th local Insuranc Mdical Practitionrs. (2)(i) Th trm of offic of th mmbrs of a local committ nominatd undr clauss (d) and () of sub-rgulation (1) shall b 19[thr yars], commncing from th dat on which thir nomination is notifid, providd that such mmbrs, shall, notwithstanding th xpiry of th said priod, continu to hold offic until th nomination of thir succssor is notifid. (ii) Th mmbrs of a local committ nominatd undr clauss (b), (c) and (f) of sub-rgulation (1) shall hold offic during th plasur of th authority nominating thm. (3) A mmbr of a local committ may rsign his offic by notic in writing to th Chairman, Rgional Board, and his sat shall fall vacant on th accptanc of th rsignation. (4)(i) A mmbr of a local committ shall cas to b a mmbr of th Committ if h fails to attnd thr conscutiv mtings throf providd that this mmbrship may b rstord by th Chairman, Rgional Board, on bing satisfid as to th unavoidabl natur of th circumstancs which ld to his non-attndanc. (ii) Whr in th opinion of th Stat Govrnmnt any prson nominatd to rprsnt mployrs or mploys on a local committ has casd to rprsnt such mployrs or mploys, th
Chairman, Rgional Board, may dclar that such prson shall cas to b a mmbr throf with ffct from such dat as may b spcifid by him. (5) Th mmbrs of th committ shall rciv such fs and allowancs as may b spcifid by th Cntral Govrnmnt. (6) Th Scrtary, shall, in consultation with th Chairman, fix th dat, tim and plac of, and also draw up th Agnda for vry mting. Notic of not lss than svn days shall ordinarily b givn to vry mmbr for such mting. No mattr othr than that includd in th Agnda shall b considrd xcpt with th prmission of th Chairman. (7) No businss shall b transactd at any mting of a committ unlss thr is a quorum of not lss than on-third of th numbr of th mmbrs of th committ. (8) All mattrs at a mting of a local committ shall b dcidd by a majority of prsons prsnt at th mting and voting, and in cas of quality of vots, th Chairman shall hav a casting vot or a scond vot. (9) A local committ shall prform th following functions in rspct of th ara for which it is st up, namly: (a) to discuss local problms in rgard to th Employs Stat Insuranc Schm so as to scur its fficint working with th full co-opration of all partis concrnd and to mak rcommndations; (b) to rfr such complaints as it may considr ncssary to th Rgional Dirctor concrnd, or in th cas of complaints concrning mdical bnfit, to th Stat Govrnmnt or such authority as that Govrnmnt may nominat for th purpos; and (c) to advis th Corporation or th Rgional Board concrnd on such mattrs as may b rfrrd to it for advic.] CHAPTER II COLLECTION OF CONTRIBUTIONS, ETC. Rgistration of Factoris or Establishmnts. 10B. (a) Th mployr in rspct of a factory or an stablishmnt to which th Act applis for th first tim and to which an Employr s Cod Numbr is not yt allottd, and th mployr in rspct of a factory or an stablishmnt to which th Act prviously applid but has casd to apply for th tim bing, shall furnish to th appropriat Rgional Offic not latr than 15 days aftr th Act bcoms applicabl, as th cas may b, to th factory or stablishmnt, a dclaration of rgistration in writing in Form 0119a[and Form 01-A] (hrinaftr rfrrd to as Employr s Rgistration Form). (b) Th mployr shall b rsponsibl for th corrctnss of all th particulars and information rquird for and furnishd on th Employr s Rgistration Form. (c) Th appropriat Rgional Offic may dirct th mployr who fails to comply with th rquirmnts of paragraph (a) of this rgulation within th tim statd thrin, to furnish to that offic Employr s Rgistration Form duly compltd within such furthr tim as may b spcifid and such mployr shall, thrupon, comply with th instructions, issud by that offic in this bhalf. 19a[(cc) Th mployr in rspct of a factory or stablishmnt to which a cod numbr has bn issud by th Corporation basd on information collctd or dcision takn rgarding applicability of th Act to such factory or stablishmnt, shall, within fiftn days or rcipt of information of allotmnt of cod numbr, furnish a dclaration in Form-01.] (d) Upon rcipt of th compltd Employr s Rgistration Form, th appropriat Rgional Offic shall, if satisfid that th factory or th stablishmnt is on to which th Act applis, allot to it an Employr s Cod Numbr (unlss th factory or th stablishmnt has alrady bn allottd an Employr s Cod Numbr) and shall inform th mployr of that numbr. () Th mployr shall ntr th Employr s Cod Numbr on all documnts prpard or compltd by him in connction with th Act, th ruls and ths rgulations and in all corrspondnc with th appropriat offic.
19a[Submission of annual information by factoris/stablishmnts. 10C. Th mployr in rspct of a factory or stablishmnt to which this Act applis and to whom a cod numbr has alrady bn allottd, shall furnish to th appropriat Rgional Offic or Sub- Rgional Offic or Divisional Offic, by 31st of January vry yar, a rturn in Form 01-A. Th mployr shall b rsponsibl for corrctnss of all particulars and information furnishd in Form 01-A.] Dclaration by prsons in mploymnt on appointd day. 11. Th mployr in rspct of a factory or an stablishmnt shall rquir vry mploy in such factory or stablishmnt to furnish and such mploy shall on dmand furnish to him ithr bfor or on th appointd day corrct particulars rquird for th purpos of Form 1 (hrinaftr rfrrd to as th Dclaration Form). Such mployr shall ntr th particulars in th Dclaration Form including th tmporary Idntification Crtificat, and obtain th signatur or th thumb-imprssion of such mploy and also complt th form as indicatd thron. Dclaration by prsons ngagd aftr th appointd day. 12. (1) Th mployr in rspct of a factory or an stablishmnt shall, bfor taking any prson into mploymnt in such factory or stablishmnt aftr th appointd day, rquir such prson (unlss h can produc an Idntity Card or othr documnt in liu throf issud to him undr ths rgulations to furnish and such prson shall on dmand furnish to him corrct particulars rquird for th Dclaration Form including th Tmporary Idntification Crtificat. Such mployr shall ntr th particulars in th Dclaration Form including th Tmporary Idntification Crtificat and obtain th signatur or th thumb imprssion of such prson and also complt th form as indicatd thron. (2) Whr an Idntity Card is producd undr such sub-rgulation (1), th mployr shall mak rlvant ntris thron. 13. 20[* * *] Dclaration Form to b snt to 21[appropriat] offic. 14. Th mployr shall snd to th appropriat 22[* * *] offic by rgistrd post or mssngr, all Dclaration Forms without dtaching th tmporary idntification crtificat prpard undr ths rgulations togthr with a rturn in duplicat in Form 3 within 10 days of th dat on which th particulars for th Dclaration Forms wr furnishd. Allotmnt of Insuranc Numbr. 15. On rcipt of th rturn rquird undr rgulation 14, th 21[appropriat] Offic shall promptly allot an Insuranc Numbr to ach prson in rspct of whom th Dclaration Form has bn rcivd unlss it finds that th prson had alrady bn allottd an Insuranc Numbr. Th tmporary Idntification Crtificat with Insuranc Numbrs markd thron shall b dtachd and rturnd to th mployr along with on copy of Form 3. Th mployr shall dlivr th Tmporary Idntification Crtificat to th mploy to whom it rlats aftr obtaining his signatur or thumb-imprssion thron xcpt in th cas of an mploy to whom a crtificat of mploymnt has bn issud undr Rgulation 17A. Th Insuranc Numbr allottd by th 21[appropriat] offic to an mploy and indicatd in th copy of Form 3 rturnd to th mployr, shall b ntrd by th mployr on th 22a[rgistr of mploys (Form 7) and rturn of contributions]. 23[Rgistration of familis. 15A. On th issu of a notification undr rgulation 95A, spcifying th dat from which th family of an insurd prson shall also b ntitld to mdical bnfit undr th Act, vry insurd
prson who has not furnishd th particulars of his family at th tim of his rgistration undr th Act, shall furnish to th mployr corrct particulars in rspct of his family in Form 1A. th mployr shall ntr th particulars in th form and obtain th signatur or th thumb imprssion of such prson and complt th form as indicatd thron and snd it to th appropriat offic on or bfor th Saturday following th nd of th wk in which th particulars wr furnishd. Changs in family. 15B. An insurd prson shall intimat all changs in th mmbrship of th family as dfind undr th Act, to th mployr within 15 days of such chang having occurrd and th mployr shall ntr such particulars in Form 23a[2] and shall forward it to th appropriat offic on or bfor th Saturday following th nd of th wk in which th particular of th changs wr furnishd.] Th Corporation to rciv assistanc from mployrs. 16. An mployr shall rndr all ncssary assistanc which th Corporation may rquir in connction with th rgistration of his factory or stablishmnt and th rgistration of his mploys and spcially for photographing such mploys and affixing th photographs to th idntity cards. 24[Idntity cards. 17. Th appropriat offic shall arrang to hav an idntity card prpard in Form 4 for ach prson in rspct of whom an insuranc numbr is allottd and shall includ in such card th particulars of th family ntitld to mdical bnfit undr rgulation 95A and shall snd all such idntity cards to th mployr. Such mployr shall if and whn th mploy has bn in his srvic for 25[3 months], obtain th signatur or thumb imprssion of th mploy on th idntity card and shall aftr making rlvant ntris thron, dlivr th idntity card to him. Th mployr shall obtain a rcipt from th mploy for th idntity card. Th idntity card in rspct of an mploy who has lft mploymnt bfor 25[3 months] shall not b givn to him, but shall b rturnd to th appropriat offic as soon as possibl. Issu of a Crtificat of Employmnt. 17A. If an insurd prson happns to nd mdical car bfor th Tmporary Idntification Crtificat is issud to him, th mployr shall issu a crtificat of mploymnt in such form as may b spcifid by th Dirctor-Gnral to such prson on dmand. Such crtification shall also b issud on dmand, if an insurd prson loss his Tmporary Idntification Crtificat bfor th rcipt of th idntity card. Issu of Prmannt Accptanc Card. 17B. In aras whr th Dirctor-Gnral considrs it appropriat, th 26[appropriat] Offic shall also supply a prmannt Accptanc Card for ach mploy in such form as th Dirctor- Gnral may spcify along with th idntity card and this shall also b dlivrd to th mploy. Prmannt Accptanc Card for th mploy who has lft mploymnt bfor 27[3 months] shall not b givn to him but rturnd to th appropriat offic along with th idntity card as soon as possibl. Loss of Idntity Card 18. In cas of loss, dfacmnt or dstruction of an Idntity Card, th insurd prson shall rport th mattr to th appropriat 27a[Branch offic], and th Corporation may issu a duplicat copy of th Idntity Card subjct to such conditions and paymnt of such fs as may b dtrmind by th Dirctor-Gnral. 19. 28[***]
20. 28[***] 21. 28[***] 22. 28a[***] 23. 28[***] Loss of Contribution Card. 24. 29[***] Rfund for contribution stamps. 25. 30[***] 31[Rturn of contributions to b snt to appropriat offic. 26. (1) Evry mployr shall snd a rturn of contributions in quadruplicat in Form 31a[5] along with rciptd copis of challans for th amounts dpositd in th Bank, to th appropriat offic by rgistrd post or mssngr, in rspct of all mploys for whom contributions wr payabl in a contribution priod, so as to rach that offic as 32[(a) within 42 days of th trmination of contribution priod to which it rlats]; 33[(b) within 21 days of th dat of prmannt closur of th factory or stablishmnt, as th cas may b]; (c) within 7 days of th dat of rcipt of rquisition in that bhalf from th appropriat offic. (2) For th purposs of sction 77 of th Act, th du dat by which th vidnc of contributions having bn paid must rach th Corporation shall b th last of th days rspctivly spcifid in clauss (a), (b) & (c) of sub-rgulation (1).] 34[Issu of crtificat of contributions. 27. An mployr shall, on dmand from th appropriat offic, issu crtificat of contributions paid or payabl in rspct of an insurd prson in such form as may b spcifid by th Dirctor- Gnral.] 28. 35[***] 36[Paymnt of contribution. 29. Contribution payabl undr th Act shall, xcpt whn othrwis providd, b paid into a Bank duly authorisd by th Corporation.] 30. 37[***] 36[Tim for paymnt of contribution. 31. An mployr who is liabl to pay contributions in rspct of any mploy shall pay thos contributions within 21 days of th last day of th calndar month in which th contributions fall du :] 38[Providd that whr a factory/stablishmnt is prmanntly closd, th mployr shall pay contribution on th last day of its closur :] 39[Providd that an mployr may opt, in such mannr as may b prscribd, by th Dirctor- Gnral for paymnt of amount in advanc towards contribution to b adjustd against contributions payabl by him (including mploys contribution) for a wag priod so that th balanc of advanc amount continus to b mor than th contributions du and payabl at th nd of th concrnd wag priod. Such an mployr shall furnish in th prscribd proforma (Form 39a[5]A), a six monthly statmnt of contributions payabl and paid in advanc with th
balanc lft at th nd of ach month along with rturn of contributions to th appropriat rgional offic of th Corporation.] 40[Intrst on contribution du, but not paid in tim. 31A. An mployr who fails to pay contribution within th priods spcifid in rgulation 31, shall b liabl to pay 41[simpl intrst at th rat of 15 pr cnt pr annum] in rspct of ach day of dfault or dlay in paymnt of contribution.] 42[Rcovry of intrst. 31B. Any intrst payabl undr rgulation 31A may b rcovrd as an arrar of land rvnu or undr sction 45C to sction 45-I of th Act.] 43[Damags or contributions or any othr amount du, but not paid in tim. 31C. An mployr who fails to pay contributions within th priods spcifid undr rgulation 31, or any othr amount payabl undr th Act, shall b liabl to pay damags as undr: Priod of dlay Rat of damags in % pr annum of th amount du (i) Up to 2 months 5% (ii) 2 months and abov but lss than 4 months (iii) 4 months and abov but lss than 6 months 10% 15% (iv) 6 months and abov 25% : Providd that th Corporation, in rlation to a factory or stablishmnt which is dclard as sick industrial company and in rspct of which a rhabilitation schm has bn sanctiond by th Board for Industrial and Financial Rconstruction, may : (a) in cas of a chang of managmnt including transfr of undrtaking(s) to workr(s) cooprativ or in cas of mrgr or amalgamation of sick industrial company with a halthy company, compltly waiv th damags lvid or lviabl; (b) in othr cass, dpnding on its mrits, waiv up to 50 pr cnt damags lvid or lviabl; (c) in xcptional hard cass, waiv ithr totally or partially th damags lvid or lviabl.] 44[Rgistr of Employs 32. (1) Evry mployr shall maintain a rgistr in Form 7 in rspct of vry mploy of his factory or stablishmnt. 45[(1a) Evry immdiat mployr shall maintain a rgistr in Form 45a[6] in rspct of vry mploy ngagd by him and submit th sam to th principal mployr bfor th sttlmnt of any amount payabl undr sub-sction (1) of sction 41 of th Act.] (2) Evry mployr shall prsrv vry rgistr maintaind undr this rgulation aftr it is filld, for a priod of fiv yars from th dat of last ntry thrin. (3) Th mployr shall giv a rasonabl opportunity to any of his mploys, if h so dsirs, to s ntris in rspct of such mploy in this rgistr onc a month.] Othr mods of paymnts of contribution. 33. Subjct to th dirctions of th Standing Committ, th Dirctor-Gnral may, if h thinks fit and subjct to such trms and conditions as h may impos, approv of any arrangmnt, 46[***], whrby contributions ar paid at tims or in a mannr othr than thos spcifid in ths rgulations and such arrangmnt may includ provision for th paymnt to th Corporation of such fs as may b dtrmind by him to rprsnt th stimatd additional
xpnss to Corporation, and may rquir such dposit of mony by way of scurity as h may dtrmin. 34. 47[***] 35. 48[***] 49[Employmnt for part of a wag priod. 36. Whr an mploy is mployd by an mployr for part of a wag priod, th contributions in rspct of such wag priod, shall fall du on th last day of th mploymnt by such mployr in that wag priod.] 37. 50[***] Schm by joint mployrs. 38. Whr an mploy is ordinarily mployd by two or mor mployrs in a 51[wag priod] th mployrs of such an mploy may, if thy think fit, submit to th Corporation a schm for th paymnt of th contributions in rspct of such mploy and th Corporation may, if it is satisfid that th schm is such as will scur th du paymnt of th contributions, approv such a schm subjct to such trms and condition as it may think ncssary: Providd that if no such schm is submittd to or approvd by th Corporation, th Corporation may spcify that any on of such mployrs shall b tratd as th mployr for th purposs of th provisions of th Act and th rgulation rlating to contributions, and in such a cas th contribution for any 51[wag priod] shall fall du on th last day of th 51[wag priod] on which an mploy was mployd by th mployr so spcifid. Rckoning of wags of mploy mployd by two or mor mployrs in th sam 52[wag priod]. 39. Whr an mploy is mployd by an mployr for only a part of th 52[wag priod] or whr an mploy is mployd by two or mor mployrs in a 52[wag priod], only th wags payabl to him for th days up to an including th day on which th contribution falls du for that 52[wag priod] shall b takn into account in rckoning wags for th purposs of dtrmining th avrag daily wags of th mploy for that 52[wag priod.] 53[Rfund of contribution rronously paid. 40. (1) Any contribution paid by a prson undr th rronous blif that th contributions wr payabl by that prson undr th Act may b rfundd without intrst by th Corporation to that prson, if application to that ffct is mad in writing bfor th commncmnt of th bnfit priod corrsponding to th contribution priod in which such contribution was paid. (2) Whr any contribution has bn paid by a prson at a rat highr than that at which it was payabl th xcss of th amount so paid ovr th amount payabl may b rfundd without intrst by th Corporation to that prson, if application to that ffct is mad bfor th commncmnt of th bnfit priod corrsponding to th contribution priod in which such contribution was paid. (3) In calculating th amount of any rfund to b mad undr this rgulation thr may b dductd th amount, if any, paid to any prson by way of bnfit on th basis of th contribution rronously paid and for th rfund of which th application is mad. (4) Whr th whol or part of th amount of any contribution rfrrd to in sub-rgulations (1) and (2), was rcovrd from an immdiat mployr or dductd from th wags of an mploy by th principal mployr, h shall, on gtting th rfund of th amount from th Corporation b
liabl to pay back th amount so rcovrd or dductd to th prson from whom th amount was so rcovrd or dductd. (5) Applications for rfund undr this rgulation shall b mad in such form and in such mannr and shall b supportd by such documnts as th Dirctor-Gnral may, from tim to tim, dtrmin.] 41. 54[***] 42. 54[***] 43. 54[***] CHAPTER III 55[BENEFITS] CLAIMS Claims for bnfits. 44. Evry claim for a bnfit payabl undr th Act shall b mad in writing, in accordanc with ths rgulations, to th appropriat 55a[Branch] Offic on th form appropriat for th purpos of th bnfit for which th claim is mad or in such othr mannr as th appropriat offic may, subjct to its bing in writing, accpt as sufficint in th circumstancs of any particular cas or class of cass. Assistanc for filling in th form of claim in cas of insurd prsons who cannot do so thmslvs shall b providd at th 55a[Branch] Offics of th Corporation. Whn claim bcoms du. 45. A claim for any bnfit undr th Act shall for th purposs of sction 77 of th Act, bcoms du on th following days : (a) For sicknss bnfit or for disablmnt bnfit for tmporary disablmnt for any priod, on th dat of th issu of th mdical crtificats in rspct of such priods; providd that in cass whr a prson is not ntitld to sicknss bnfit for th first two days of sicknss, th du dat shall b dfrrd by such days. (b) For matrnity bnfit (i) in cas of confinmnt, on th dat of issu, in accordanc with ths rgulations, of crtificat of xcptd confinmnt or on th day six wks prcding th xpctd dat of confinmnt so crtifid whichvr is latr or, if no such crtificat is issud, on th dat of confinmnt; and (ii) in cas of miscarriag and in cas of sicknss arising out of prgnancy, confinmnt, prmatur birth of child or miscarriag, on th dat of issu of th mdical crtificat of such miscarriag or sicknss, as th cas may b; (c) for 57[first paymnt of] disablmnt bnfit for prmannt disablmnt, on th dat in which an insurd prson is dclard as prmanntly disabld in accordanc with th Act and ths rgulations; and 56[(d) for 57[first paymnt of] dpndnts bnfit, on th dat of th dath of th insurd prson in rspct of whos dath th claim for such bnfit ariss or, whr disablmnt bnfit was payabl for that dat, on th dat following th dat of dath or, whr th bnficiary bcoms ntitld to a claim on any subsqunt dat, on th dat on which h bcoms so ntitld;] 57[) for subsqunt paymnts of disablmnt bnfit for prmannt disablmnt and for subsqunt paymnt of dpndnts bnfit, th last dat of th month to which th claim rlats;] (f) for funral 58[xpnss] on th dat of th dath of th insurd prson in rspct of whos dath th claim for such bnfit ariss.
Availability of claim forms. 46. Claim form shall b availabl to intnding claimants from such prsons and such offics of th Corporation as it may appoint or authoris for that purpos, and shall b supplid fr of charg. Claim on wrong form. 47. Whr a claim for any bnfit has bn mad on an approvd form othr than th form appropriat to th bnfit claimd, th Corporation may trat th claim as if it was mad on th appropriat form; providd that th Corporation may in any such cas rquir th claimant to complt th appropriat form. Evidnc in support of claim. 48. Evry prson who maks a claim for any bnfit shall in addition to th mdical crtificat and othr forms spcifically rquird undr ths rgulations, furnish such othr information and vidnc for th purpos of dtrmining th claim as may b rquird by th appropriat offic, and, if rasonably so rquird, shall for that purpos attnd at such offic or plac as th appropriat offic may dirct. Dfctiv claim. 49. If, in absnc of du signatur or of du crtification, a claim is dfctiv on th dat of its rcipt by an offic of th Corporation th offic of th Corporation may in its discrtion rfr th claim to th claimant and if th form is rturnd duly signd and/or crtifid within thr months from th dat on which it was so rfrrd, th offic may trat th claim as if it had bn duly mad in th first instanc. Claim for inappropriat bnfit. 50. Whr it appars that a prson who has mad a claim for any bnfit payabl undr th Act, may b ntitld to a bnfit othr than that which h has claimd, any such claim may b tratd as a claim in th altrnativ for that othr bnfit. Authority for crtifying ligibility of claimants. 51. Th authority which is to crtify th ligibility of claimants shall b th appropriat 55a[Branch] Offic in rspct of matrnity, sicknss, tmporary disablmnt 59[bnfits and funral xpnss] and th appropriat Rgional Offic, in rspct of prmannt disablmnt and dpndnt s bnfits. 60[Bnfits whn payabl 52. (1) Any bnfit payabl undr th Act shall b paid (a) in th cas of sicknss bnfit not latr than 7 days; 61[(b) in th cas of funral xpnss not latr than 15 days;] (c) in th cas of first paymnt in rspct of matrnity bnfit not latr than 14 days; (d) in th cas of th first paymnt in rspct of Tmporary Disablmnt Bnfit not latr than on month; () in th cas of first paymnt of Prmannt Disablmnt Bnfit not latr than on month; (f) in th cas of first paymnt of Dpndnts Bnfits not latr than 3 months, aftr th claim thrfor togthr with th rlvant mdical or othr crtificats and any othr documntary vidnc which may b calld for undr ths Rgulations has bn furnishd complt in all particular to th appropriat offic.] (2) Scond and subsqunt paymnts in rspct of any matrnity, tmporary disablmnt, prmannt disablmnt or dpndnts bnfit shall b paid along with th first paymnt in rspct throf or within th calndar month following th month to th whol or part of which
thy rlat, whichvr is latr subjct to production of any documntary vidnc which may b rquird undr ths rgulations. (3) Whr a bnfit paymnt is not mad within th tim limits spcifid in sub-rgulations (1) and (2) abov, it shall b rportd to th 62[appropriat Rgional Offic] and shall b paid as soon as possibl. 63[(4) Bnfits undr th Act shall b paid in cash at a 55a[Branch] Offic on such days and working hours, as may b fixd by th Dirctor-Gnral, or such othr officr of th Corporation, as may b authorisd by him from tim to tim in this bhalf, or, at th option of th claimant and subjct to dduction of th cost of rmittanc, by mans of postal mony ordrs or othr ordrs payabl through a post offic, or by any othr mans, which th appropriat offic may in th circumstancs of any particular cas considr appropriat: Providd that th Corporation may waiv th dduction of th cost of rmittanc in such cass as th Dirctor-Gnral may, from tim to tim, spcify.] (5) Whr th paymnt of a bnfit is to b mad at a 55a[Branch] Offic, such offic may insist upon th production of th Idntity Card or othr documnt issud in liu throf in rspct of th insurd prson. 64[Abstntion vrification. 52A. 65[(1)] Evry mployr shall furnish to th appropriat offic such information and particulars in rspct of th abstntion of an insurd prson from work for which sicknss bnfit 66[***] or disablmnt bnfit for tmporary disablmnt, as providd undr th Act has bn claimd or paid, in Form No. 66a[10] and within such tim as th said offic may in writing rquir in th said form.] 67[(2) Evry mployr shall furnish to th appropriat offic such information and particulars in rspct of th abstntion of an insurd woman from work for which matrnity bnfit as providd undr th Act has bn claimd or paid, in Form 66a[10] and within such tim as th said offic may in writing rquir in th said Form.] CERTIFICATION AND CLAIMS FOR SICKNESS AND TEMPORARY DISABLEMENT Evidnc of sicknss and tmporary disablmnt. 53. Evry insurd prson, claiming sicknss bnfit or disablmnt bnfit for tmporary disablmnt, shall furnish vidnc of sicknss or tmporary disablmnt in rspct of th days of his sicknss or tmporary disablmnt by mans of a mdical crtificat givn by an Insuranc Mdical Officr in accordanc with ths rgulations in th form appropriat to th circumstancs of th cas: Providd that in aras whr arrangmnt for mdical bnfit undr th Employs Stat Insuranc Act hav not bn mad or othrwis if in its opinion th circumstancs of a particular cas so justify, th Corporation may accpt any othr vidnc of sicknss or tmporary disablmnt in th form of a crtificat issud by th mdical officr of th Stat Govrnmnt, local body or othr mdical institution, or a crtificat issud by any rgistrd mdical practitionr containing such particulars and attstd in such mannr as may b spcifid by th Dirctor-Gnral in this bhalf. Prsons comptnt to issu mdical crtificat. 54. No mdical crtificat undr ths rgulations shall b issud xcpt by th Insuranc Mdical Officr to whom an insurd prson has bn allottd or by an Insuranc Mdical Officr attachd to a dispnsary, hospital, clinic or othr institution to which and insurd prson is allottd and such Insuranc Mdical Officr shall xamin and if in his opinion th condition of th insurd prson so justifis, issu to such insurd prson fr of charg, any mdical crtificats rasonably rquird by such insurd prson undr or for th purposs of th Act or any othr nactmnt or ths rgulations:
Providd that an Insuranc Mdical Officr may issu a mdical crtificat undr ths rgulations to a insurd prson who is not allottd to him or to th dispnsary, hospital, clinic or othr institution to which h is attachd, if such officr is satisfid that in th circumstancs of any particular cas th insurd prson cannot rasonably b xpctd to gt mdical bnfit from th Insuranc Mdical Officr or th dispnsary, hospital, clinic or othr institution to which such insurd prson has bn allottd; and such crtificat shall also b issud fr of charg : Providd furthr that an insurd prson shall not b grantd a mdical crtificat unlss h producs to th Insuranc Mdical Officr his Idntity Card or such othr Documnts as undr ths rgulations, may hav bn issud in liu throf. Mdical crtificat. 55. Th appropriat form of a mdical crtificat shall b filld in ink or othrwis as may b spcifid by th Dirctor-Gnral by th Insuranc Mdical Officr in his own handwriting and shall contain a concis statmnt of th disas or disablmnt which in th opinion of th Insuranc Mdical Officr ncssitats abstntion from work on mdical grounds or rndrs th prson tmporarily incapabl of work. Th statmnt of th disas or disablmnt in th mdical crtificat shall spcify th natur throf as prcisly as th Insuranc Mdical Officr s knowldg of th condition of th insurd prson at th tim of th xamination prmits. Tim of granting mdical crtificat. 56. (a) An Insuranc Mdical Officr shall giv th mdical crtificat to an insurd prson at th tim of th xamination to which it rlats; whr h is prvntd from so doing h shall snd th crtificat to th insurd prson within twnty-four hours thraftr. (b) No furthr mdical crtificat rlating to th sam xamination shall b issud, xcpt whr a duplicat of such crtificat is rquird, in which cas it shall b issud fr of charg and clarly markd Duplicat. 68[Mdical crtificat on first xamination. 57. Whr th xamination is th first xamination in rspct of a spll of sicknss or a spll of tmporary disablmnt, th mdical crtificat shall b in th form of a first crtificat (Form 68a[7]) and shall b only in rspct of th dat of xamination: 69[Providd that whr th insurd prson, who nds abstntion from work on th day of xamination, stats that h has bn actually sick or tmporarily disabld on a day arlir than th dat of his first xamination, th Insuranc Mdical Officr may, if h is satisfid as to th truth of th statmnt that th insurd prson was unabl to prsnt himslf for mdical xamination arlir for rasons byond his control, crtify incapacity for work on th dat prcding th dat of xamination:] Providd 69[furthr] that whr in th opinion of th Insuranc Mdical Officr, th insurd prson is likly to bcom fit to rsum work on a dat not latr than th third day aftr th dat of th xamination, th first crtificat may b issud in rspct of th ntir spll of sicknss or tmporary disablmnt, and, in such a cas, it shall spcify th dat on which th insurd prson will, in his opinion, b fit to rsum work; such a crtificat shall, notwithstanding anything containd in th rgulations, b also tratd as a final crtificat.] Final mdical crtificat. 58. If at th dat of th xamination to which a mdical crtificat othr than a first crtificat rlats, th insurd prson in th opinion of th Insuranc Mdical Officr is, or will bcom on a dat not latr than th third day aftr that dat, fit to rsum work, that crtificat shall b in th form of a final crtificat (Form 68a[7]). Intrmdiat crtificat.
59. If th final crtificat is not issud within svn days of th dat of th first crtificat, an insurd prson shall, xcpt whr th cas is covrd by rgulation 61, submit crtificats in th form of intrmdiat crtificats (Form 68a[7]) at intrvals of not mor than svn days ach, commncing from th dat of th first crtificat. Final mdical crtificat bfor commncing work for wags. 60. Evry insurd prson shall obtain a mdical crtificat in th form of a final crtificat bfor h taks up any work for wags. Intrmdiat crtificat for a longr priod 70[***]. 61. Whn tmporary disablmnt 71[or sicknss] has continud for not lss than twnty-ight days and th Insuranc Mdical Officr is satisfid that such disablmnt 71[or sicknss] is likly to continu for a long priod and that, owing to th natur of th disablmnt 71[or sicknss] xamination and tratmnt at intrvals of mor than on wk will b sufficint, th insurd prson may, unlss othrwis dirctd by th appropriat offic, furnish mdical crtificats in th form of spcial intrmdiat crtificats (Form 71a[8]) at intrvals of such longr priods not xcding four wks as may b spcifid by th Insuranc Mdical Officr. 62. [***] Form of claim for sicknss or tmporary disablmnt. 63. An insurd prson intnding to claim sicknss bnfit or disablmnt bnfit for tmporary disablmnt shall submit to th appropriat 55a[Branch] Offic by post or othrwis, a claim for bnfit in on of th 71a[Form 9] appropriat to th circumstancs of th cas togthr with th appropriat mdical crtificat: 72[Providd that whr only on claim in 71a[Form 9] is submittd in rspct of mor than on crtificats, such 71a[Form 9] shall b dmd to b appropriat to all such crtificats.] Failur to submit mdical crtificat. 64. If a prson who intnds to claim sicknss bnfit or disablmnt bnfit for tmporary disablmnt fails to submit to th appropriat 55a[Branch] Offic by post or othrwis th first mdical crtificat or any subsqunt mdical crtificat within a priod of thr days from th dat of issu of such crtificat h shall not b ligibl for that bnfit in rspct of any priod (i) in th cas of a first crtificat, mor than thr days bfor th dat on which th crtificat is submittd to th appropriat 55a[Branch] Offic; (ii) in th cas of a subsqunt crtificat, mor than fourtn days bfor th dat on which such subsqunt crtificat is submittd to th appropriat 55a[Branch] Offic : 73[Providd that th appropriat Rgional Offic 73[or othr offic as authorisd by th Dirctor- Gnral] may rlax all or any of th provisions of this rgulation in any particular cas, if it is satisfid that th dlay in submitting a crtificat was du to bona fid rasons.] DISABLEMENT BENEFIT Notic of accidnt. 65. (i) Evry insurd prson who sustains prsonal injury causd by accidnt arising out of and in th cours of his mploymnt in a factory or stablishmnt shall giv notic of such injury ithr in writing or orally, as soon as practicabl aftr th happning of th accidnt: Providd that any such notic rquird to b givn by an insurd prson may b givn by som othr prson acting on his bhalf. 74[Explanation : No such notic shall b rquird to b givn by an insurd prson if an mploymnt injury is causd by any Occupational Disas spcifid in Schdul III to th Workmn s Compnsation Act, 1923.]
(ii) Evry such notic shall b givn to th mployr or to a forman or to othr official undr whos suprvision th insurd prson is mployd at th tim of th accidnt or any othr prson dsignatd for th purpos by th mployr and shall contain th appropriat particulars. (iii) Any ntry of th appropriat particulars of th accidnt mad in a book kpt for that purpos in accordanc with th nxt following rgulation shall, if mad as soon as practicabl aftr th happning of th accidnt by th insurd prson or by som othr prson acting on his bhalf, b sufficint notic of th accidnt for th purposs of ths rgulations. (iv) In this rgulation and th nxt following rgulation, th xprssion appropriat particulars mans th particulars indicatd blow (a) full nam, insuranc numbr, sx, ag, addrss, occupation, dpartmnt and shift of th injurd prson; (b) dat and tim of accidnt; (c) plac whr accidnt happnd; (d) caus and natur of injury; () nam, addrss and occupation of th prson giving th notic, if h is othr than th injurd prson; (f) a statmnt of what xactly th injurd prson was doing at th tim of injury; (g) nam, addrsss and occupation of two prsons who wr prsnt at th spot whn accidnt happnd; and (h) rmarks, if any. Maintnanc of accidnt book. 66. Evry mployr shall (i) kp a book radily accssibl (hrinaftr calld th Accidnt Book ) in Form 74a[11], in which th appropriat particulars of any accidnt causing prsonal injury to an insurd prson may b ntrd; (ii) Prsrv vry such book whn it is compltd for a priod of fiv yars from th dat of th last ntry thron: 75[Providd that it shall not b ncssary to ntr in th said Accidnt Book particulars of any mploymnt injury causd by an Occupational Disas spcifid in Schdul III to th Workmn s Compnsation Act, 1923.] Notic othrwis than by an ntry in accidnt book. 67. If notic of an mploymnt injury undr rgulation 65 is givn othrwis than by an ntry in th Accidnt Book it shall b th duty of th mployr or any othr prson to whom such notic is givn undr that rgulation to mak an appropriat ntry in th book in rspct of th accidnt to which th notic rlats immdiatly aftr such notic is rcivd, and whr th notic is rcivd othrwis than in writing, rad ovr th particulars to th prson who givs th notic and obtains his signatur or thumb-imprssion on th Accidnt Book. Rport of accidnt by an mployr. 68. Evry mployr shall snd a rport in Form 75a[12] to th narst 55a[Branch] Offic and to th narst Insuranc Mdical Officr (i) immdiatly if th injury is srious, i.., it is likly to caus dath or prmannt disablmnt or loss of a mmbr; and (ii) in any othr cas within 24 hours aftr th rcipt of th notic undr rgulation 65 or of th tim whn th accidnt cam to th notic of th mployr or of a forman or othr official undr whos suprvision th insurd prson was mployd at th tim of th accidnt or any othr prson dsignatd for th purpos by th mployr: Providd that in cas of a srious injury, and particularly whn th injury rsults in dath at th plac of mploymnt, th rport to th Insuranc Mdical Officr and th 55a[Branch]
Officr shall b snt through a spcial mssngr, or othrwis, as spdily as may b practicabl undr th circumstancs: Providd furthr that whr a rport of th accidnt is mad by th mployr undr th Factoris Act, 1948, th rport to th 55a[Branch] Offic and to th Insuranc Mdical Officr may b mad in th sam form as is prscribd undr th Factoris Act, 1948, providd that all th additional information rquird undr Form 75b[12] is addd thrto: 76[Providd furthr that it shall not b ncssary for th mployr to snd a rport in Form 75b[12] if an mploymnt injury is causd by any Occupational Disas spcifid in Schdul III to th Workmn s Compnsation Act, 1923; but th mployr shall furnish on dmand to th appropriat 55a[Branch] Offic, within such rasonabl priod as may b spcifid, such information and particulars as shall b rquird of th natur of and othr rlvant circumstancs rlating to any mploymnt spcifid in Schdul III to th Workmn s Compnsation Act, 1923.] Employr to arrang first aid. 69. Evry mployr shall arrang for such first aid and mdical car and transport for obtaining such aid and car as th circumstancs of th accidnt may rquir till th injurd prson is sn by th Insuranc Mdical Officr and such mployr shall b ntitld to rimbursmnt in rspct of xpnss thrby incurrd by him but not xcding such scal of xpnss as may b spcifid by th Corporation from tim to tim: Providd that if th mployr is rquird to provid such mdical aid fr of charg undr any othr nactmnt, h shall not b ntitld to any rimbursmnt of xpnss. Employr to furnish furthr particulars of accidnt. 70. Evry mployr shall furnish to th appropriat offic such furthr information and particulars of an accidnt and within such tim as th said offic may, in writing, rquir. Dirctions by th Corporation. 71. Evry claimant for and vry bnficiary in rcipt of disablmnt bnfit shall comply with vry dirction givn to him by th appropriat Rgional Offic which rquirs him ithr (i) to submit himslf to a mdical xamination by such mdical authority as may b appointd by that offic for th purpos of dtrmining th ffct of th rlvant mploymnt injury or th tratmnt appropriat to th rlvant injury or loss of faculty, or (ii) to attnd any vocational training courss or industrial rhabilitation courss providd by any institution maintaind by any Govrnmnt, local authority or any public or privat body, rcognisd for th purpos by th Corporation and considrd appropriat by it in his cas. Rfrnc to a Mdical Board. 72. A rfrnc to th Mdical Board may b mad 77[(a) at any tim not latr than twlv months, in cass whr claim for tmporary disablmnt bnfit is mad for an mploymnt injury, from th dat of th final crtificat issud in rspct of th spll of tmporary disablmnt commncing on or immdiatly aftr th day of th occurrnc of that injury, or from th dat of th occurrnc of an mploymnt injury in cass whr tmporary disablmnt bnfit not having bn claimd claim for prmannt disablmnt is mad on th basis throf, by th appropriat Rgional Offic at th instanc of th disabld prson or th mployr or any rcognisd mploy s union: Providd that such rfrnc may b mad by th appropriat Rgional Offic aftr th xpiry of th priod prscribd as aforsaid if it is satisfid that th applicant was prvntd by sufficint caus from applying for th making of th rfrnc in tim: Providd furthr that in th vnt of th claim for Tmporary Disablmnt Bnfit bing rjctd by th Corporation but aftrwards grantd by th Employs Insuranc Court in rspct of injuris rsultd in Prmannt disablmnt, th limit of 12 months will apply
from th dat of th ordr of th Employs Insuranc Court granting th claim of th insurd prson for Tmporary Disablmnt Bnfit, or] (b) by th Corporation, (i) at any tim, on th rcommndation of an Insuranc Mdical Officr, and (ii) on its own initiativ, aftr th xpiry of th priod of twnty-ight days from th first dat on which th claimant was rndrd incapabl of work by th rlvant mploymnt injury. Rport of Mdical Board. 73. Th Mdical Board shall aftr xamining th disabld prson snd its dcision on such form as may b spcifid by th Dirctor-Gnral, to th appropriat Rgional Offic. Th disabld prson shall b informd in writing of th dcision of th Mdical Board and th bnfit, if any, to which th disabld prson shall b ntitld. Occupational Disas. 74. Any qustion whthr an mploymnt injury is causd by an Occupational Disas spcifid in th Third Schdul to th Act shall b dtrmind by a Spcial Mdical Board which shall xamin th disabld prson and snd a rport in such form as may b prscribd by th Dirctor Gnral in this bhalf to th appropriat Rgional Offic stating : (a) whthr th disabld prson is suffring from on or mor of th disass spcifid in th said schdul; (b) whthr th rlvant disas has rsultd in prmannt disablmnt; (c) whthr th xtnt of loss of arning capacity can b assssd provisionally or finally; (d) th assssmnt of th proportion of loss of arning capacity and in cas of provisional assssmnt, th priod for which such assssmnt shall hold good. All assssmnts which ar provisional may b rfrrd to th Spcial Mdical Board for rviw by th appropriat Rgional Offic not latr than th nd of th priod takn into account by th provisional assssmnt. Any dcision of th Spcial Mdical Board may b rviwd by it at any tim. Th disabld prson shall b informd in writing of th dcision of th Spcial Mdical Board by th appropriat Rgional Offic and th bnfit, if any, to which th insurd prson shall b ntitld. 78[Constitution of Mdical Board/Spcial Mdical Boards. 75. Mdical Boards for th purposs of th Act and th Spcial Mdical Boards for th purposs of rgulation 74 shall b constitutd by th Corporation and whr it so dsirs it may approach th Stat Govrnmnt for stting up th sam and shall consist of such prsons, hav such jurisdiction and follow such procdur as th Dirctor-Gnral may from tim to tim dcid.] 79[Appal Tribunals. 76. For th purposs of rgulation 74, an Appal Tribunal shall b constitutd by th Stat Govrnmnt and shall consist of a judicial officr of th Stat Govrnmnt bing a prson othr than th judg of an Employs Insuranc Court, who shall b assistd by th following prsons to b slctd by him as assssors : (a) On or mor mdical xprts; (b) On or mor official of or mmbrs of Trad Union or Unions.] 80[81[Submission of claims for prmannt disablmnt bnfit.] 76A. An insurd prson who has bn dclard to b prmanntly disabld by a Mdical Board or by an Appal Tribunal shall submit by post or othrwis, to th appropriat 55a[Branch] Offic
a claim, covring, xcpt in th cas of a first paymnt, a priod of on or mor complt calndar months in Form 81a[14] for claiming prmannt disablmnt bnfit.] 82[82a[Commutation of prmannt disablmnt bnfit.] 76B. 83[(1) An insurd prson whos prmannt disablmnt has bn assssd as final and who has bn awardd prmannt disablmnt bnfit at a rat not xcding Rs. 1.50 pr day may apply for commutation of prmannt disablmnt bnfit into a lump sum: Providd that th insurd prson whos prmannt disablmnt has bn assssd as final and th bnfit rat xcds Rs. 1.50 pr day may also apply for commutation of prmannt disablmnt bnfit into lump sum subjct to th condition that th total commutd valu of th lump sum prmannt disablmnt bnfit dos not xcd Rs. 10,000 at th tim of commncmnt of final award of his prmannt disability : Providd furthr that th cass falling undr claus (3) of this rgulation whr commutation has bn rfusd bcaus th insurd prson did not hav avrag xpctation of lif, shall not b ropnd.] (2) Whr such an application is mad within 6 months of th dat on which h can opt for commutation hraftr calld th dat of possibl option 84[prmannt disablmnt bnfit] shall b commutd into a lump sum. (3) Whr such an application is mad aftr xpiry of six months from th dat of possibl option, 84[prmannt disablmnt bnfit] may b commutd into lump sum if th corporation is satisfid that th insurd prson has an avrag xpctation of lif for his ag. For this purpos, th insurd prson shall, if so rquird by th appropriat offic, prsnt himslf for xamination by such mdical authority as th Dirctor-Gnral may, by gnral or spcial ordr, spcify. (4) For th purpos of this rgulation, th dat of possibl option shall man (i) in th cas of a prson who, on th dat on which this rgulation coms into forc, is in rcipt of prmannt disablmnt bnfit covrd by sub-rgulation (1) th dat of coming into forc of this rgulation; (ii) in th cas of any othr insurd prson, th dat on which assssmnt of prmannt disablmnt covrd by sub-rgulation (1), is communicatd to him by th appropriat Rgional Offic. (5) Th amount of lump sum admissibl undr this rgulation shall b dtrmind by multiplying th daily rat of prmannt disablmnt bnfit by th figur indicatd in Column 2 of th Schdul III to ths rgulations, corrsponding to th ag on last birthday of th insurd prson on th dat on which his application for commutation is rcivd in th appropriat offic and on and from that dat 85[th] prmannt disablmnt bnfit shall cas to b payabl to him] : 86[Providd that whr no proof of ag has bn submittd as rquird by th appropriat offic or if submittd, has not bn accptd as satisfactory by th appropriat offic, th corrsponding ag as aforsaid of th insurd prson shall b th ag as stimatd by th Mdical Board on th dat of xamination adjustd by th priod intrvning btwn th dat of xamination by th Mdical Board and th dat on which th application for commutation was rcivd in th appropriat offic: Providd furthr that th ag so stimatd by th Mdical Board shall also oprat against any proof of ag that may b submittd aftr th tim allowd for th purpos to th insurd prson by th appropriat offic bfor rfrnc of his cas to th Mdical Board.] DEPENDENTS BENEFIT Rport of dath of insurd prson by mploymnt injury. 77. In cas of dath of an insurd prson as a rsult of an mploymnt injury (a) if th dath occurs at th plac of mploymnt th mployr shall, and (b) if th dath occurs at any othr plac, a dpndnt intnding to claim dpndants bnfit shall, or (c) any othr prson prsnt at th tim of dath may,
immdiatly rport th dath to th narst 55a[Branch] Offic and to th narst dispnsary, hospital, clinic or othr institution whr mdical bnfit undr th Act is availabl. Disposal of body of an insurd prson dying by mploymnt injury. 78. Whr an insurd prson dis as a rsult of an mploymnt injury sustaind as an mploy undr th Act, th body of th insurd prson shall not b disposd of until th body has bn xamind by, an Insuranc Mdical Officr, who will also arrang a post-mortm xamination, if considrd ncssary, in co-opration with any othr xisting agncy: Providd that if an Insuranc Mdical Officr is unabl to arriv for th xamination within 12 hours of such dath th body may b disposd of aftr obtaining a crtificat from such mdical officr or practitionr as may b availabl: Providd furthr that nothing containd in this rgulation shall b in drogation of any powr confrrd on a coronr undr any law for th tim bing in forc or on th officr-in-charg of a polic station or som othr polic officr undr 87[sction 174 of th Cod of Criminal Procdur, 1973 (2 of 1974).] Issu of dath crtificat. 79. An Insuranc Mdical Officr attnding th disabld prson at th tim of his dath or th Insuranc Mdical Officr who xamins th body aftr th dath or th Mdical Officr who attndd th insurd prson in a hospital or othr institution whr such disabld prson did, shall issu fr of charg a dath crtificat in Form 87a[13] to th dpndants of th dcasd and shall snd a rport to th appropriat Rgional Offic. Submission of claim for dpndants bnfit. 80. (1) A claim for dpndants bnfit shall b submittd to th appropriat 55a[Branch] Offic by post or othrwis in Form 87b[15] by th dpndant or dpndants concrnd or by thir lgal rprsntativ or, in cas of a minor, by his guardian, and such claim shall b supportd by documnts proving (i) that th dath is du to an mploymnt injury; 88[(ii) that th prson claiming is a dpndnt ntitld to claim as providd in rul 58 of th Employs Stat Insuranc (Cntral) Ruls, 1950;] (iii) th ag of th claimant; (iv) th infirmity of th dpndnt claiming to b infirm within th purviw of 89[rul 58 of th Employs Stat Insuranc (Cntral) Ruls, 1950] by a crtificat of such mdical or othr authority as th Dirctor-Gnral may, by a gnral or spcial ordr spcify in this bhalf : Providd that whr th appropriat Rgional Offic is satisfid about th bona fids of th applicant or about th truth of th facts rlating to any of th mattrs mntiond abov, on or mor of th documnts may b dispnsd with. (2) Th following may b accptd as proof of ag (a) crtifid xtract from an official rcord of births showing th dat and plac of birth and fathr s nam; (b) original horoscop prpard soon aftr birth; (c) crtifid xtract from baptismal rgistr; (d) crtifid xtract from school rcord showing th dat of birth and fathr s nam; () such othr vidnc as may b accptabl to th appropriat Rgional Offic in th circumstancs of a particular cas. Notic for dpndants bnfit. 81. On rcipt of a claim or claims for dpndants bnfit in rspct of th dath of an insurd prson and, aftr making such inquirs as may b ncssary about th circumstancs and caus of dath and about all prsons, who may b ntitld to dpndants bnfit, th appropriat
Rgional Offic shall issu by rgistrd post to such othr prsons, if any, as appar on nquiry to b ntitld to dpndants bnfit, and who hav not yt submittd a claim for such bnfit a notic for submission of claims for dpndants bnfit within a priod of thirty days from th dat of such notic. Th notic shall indicat intr alia th rlvant provisions of th Act and rgulations and th procdur for submission of a claim for dpndants bnfit. Intimation of dcision rgarding dpndants bnfit. 82. As soon as possibl aftr th xpiry of th priod during which claims can b submittd in trms of th notic issud undr rgulation 81, th appropriat Rgional Offic shall intimat by rgistrd post th dcision of th Corporation in rgard to th claim of ach of th dpndants in writing to th dpndants concrnd or to his lgal rprsntativ, or, in th cas of a minor, to his guardian. Dat of accrual of dpndants bnfit. 83. Th dpndant s bnfit shall accru from th dat of th dath in rspct of which th bnfit is payabl, 90[or, whr disablmnt bnfit was payabl for that dat from th dat following th dat of dath.] 91[Submission of claims for priodical paymnts of dpndants bnfit. 83A. Each dpndant whos claim for dpndants bnfit is admittd undr rgulation 82, shall submit to th appropriat 55a[Branch] Offic, by post or othrwis, a claim covring, xcpt in th cas of first or a final paymnt a priod of on or mor complt calndar months in Form 91a[16]. Such claim may b mad by th lgal rprsntativ of a bnficiary or in th cas of a minor, by his guardian.] Rviw of dpndants bnfit. 84. (1) Th amounts payabl as dpndnts bnfit in rspct of th dath of any insurd prson may b rviwd by th appropriat Rgional Offic at its own initiativ, and shall b so rviwd if an application is mad to that ffct, undr any of th following circumstancs (a) if any of th bnficiaris cass to b ntitld to th dpndants bnfit by rason of marriag, r-marriag, dath, ag or othrwis, or (b) if a frsh dpndant is admittd to th claim for dpndants bnfit by th birth of a posthumous child, or (c) if, aftr th prvious dcision as to th distribution of th dpndnts bnfit was takn, som facts matrially, affcting such distribution com to light. (2) Any rviw undr this rgulation shall b mad aftr giving du notic by rgistrd post to ach of th dpndants, stating thrin th rasons for th proposd rviw and giving thm an opportunity to submit objctions, if any, to such rviw. (3) Subjct to th provisions of th Act and ths rgulations, th appropriat Rgional Offic may, as a rsult of such rviw, commnc, continu, incras, rduc or discontinu from such dat as it may dcid th shar of any of th dpndants. 85. 92[***] Appointmnt of anothr guardian. 86. If at any tim th appropriat Rgional Offic is satisfid that a child who is in rcipt of dpndants bnfit is bing nglctd by his guardian, not bing a guardian appointd undr th Guardian and Wards Act, 1890, and th child s shar of th dpndants bnfit is not bing proprly spnt on his or hr maintnanc, th appropriat Rgional Offic may dirct that such shar may b paid subjct to such conditions as it may spcify to such othr prson as it dms fit and as in its opinion would utilis it for th car and maintnanc of th child. MATERNITY BENEFIT
Notic of prgnancy. 87. An insurd woman, who dcids to giv notic of prgnancy bfor confinmnt, shall giv such notic in Form 91a[17] to th appropriat 55a[Branch] Offic by post or othrwis and shall submit, togthr with such notic, a crtificat of prgnancy in Form 20 givn in accordanc with ths rgulations on a dat not arlir than svn days bfor th dat on which such notic is givn. Claim for matrnity bnfit commncing bfor confinmnt. 88. Evry insurd woman claiming matrnity bnfit bfor confinmnt shall submit to th appropriat 55a[Branch] Offic by post or othrwis (i) a crtificat of xpctd confinmnt in Form 92b[18] givn in accordanc with ths rgulations, not arlir than fiftn days bfor th xpctd dat of confinmnt; (ii) a claim for matrnity bnfit in Form 92c[19] stating thrin th dat on which sh casd or will cas to work for rmunration; and (iii) within thirty days of th dat on which hr confinmnt taks plac, a crtificat of confinmnt in Form 92b[18] givn in accordanc with ths rgulations. Claim for matrnity bnfit only aftr confinmnt or for miscarriag. 89. Evry insurd woman claiming matrnity bnfit for miscarriag shall within 30 days of th dat of th miscarriag, and vry insurd woman claiming matrnity bnfit aftr confinmnt, shall submit to th appropriat offic by post or othrwis a claim for matrnity bnfit in Form 92c[19] togthr with a crtificat of confinmnt or miscarriag in Form 92b[18] givn in accordanc with ths rgulations. Claim for matrnity bnfit aftr th dath of an insurd woman laving bhind th child. 89A. For th purposs of th proviso to sub-sction (2) of sction 50 of th Act, th prson nominatd by th dcasd insurd woman on Form 1 or on such othr Form as may b spcifid by th Dirctor-Gnral in this bhalf and if thr is no such nomin, th lgal rprsntativ, shall submit to th appropriat offic by post or othrwis a claim for matrnity bnfit, as may b du, in Form 92d[20] within 30 days of th dath of th insurd woman togthr with a dath crtificat in Form 92[21] givn in accordanc with ths Rgulations. Claim for matrnity bnfit in cas of sicknss arising out of prgnancy, confinmnt, prmatur birth of child or miscarriag. 89B. (1) Evry insurd woman claiming matrnity bnfit in cas of sicknss arising out of prgnancy, confinmnt, prmatur birth of child or miscarriag, shall submit to th appropriat offic by post or othrwis a claim for bnfit in on of th 93[Form 9] appropriat to th circumstancs of th cas togthr with th appropriat mdical crtificat in Form 93a[7] or 93b[8], as th cas may b, givn in accordanc with ths Rgulations. (2) Th provisions of rgulations 55 to 61 and 64 shall, so far as may b, apply in rlation to a claim submittd and a crtificat givn in accordanc with this rgulation as thy apply to crtification and claims undr thos rgulations. Othr vidnc in liu of a crtificat. 90. Th Corporation may accpt any othr vidnc in liu of a crtificat of prgnancy, xpctd confinmnt, confinmnt, dath during matrnity, miscarriag or sicknss arising out of prgnancy, confinmnt, prmatur birth of child or miscarriag by an Issuranc Mdical Officr, if in its opinion, th circumstancs of any particular cas so justify. Notic of work for rmunration.
91. Excpt as providd in rgulation 89B vry insurd woman who has claimd matrnity bnfit shall giv notic in Form 93c[19] if sh dos work for rmunration on any day during th priod for which matrnity bnfit would b payabl to hr but for hr working for rmunration. Dat of paymnt of matrnity bnfit. 92. Matrnity bnfit shall b payabl from th dat from which it is claimd providd that such dat dos not prcd th xpctd dat of confinmnt by mor than forty-two days, and that no work is undrtakn by th insurd woman for rmunration. Disqualification for matrnity bnfit. 93. An insurd woman may b disqualifid from rciving matrnity bnfit if sh fails without good caus to attnd for or to submit hrslf to mdical xamination whn so rquird; and such disqualification shall b for such numbr of days as may b dcidd by th authority authorisd by th Corporation in this bhalf: Providd that a woman may rfus to b xamind by othr than a fmal doctor or midwif. Authority which may issu crtificat. 94. No crtificat rquird undr any of th rgulations 87 to 89B shall b issud xcpt by th Insuranc Mdical Officr to whom th insurd woman has or had bn allottd or by an Insuranc Mdical Officr attachd to a dispnsary, hospital, clinic or othr institution to which th insurd woman is or was allottd and such Insuranc Mdical Officr shall xamin and if in his opinion th condition of th woman so justifis or in cas of dath of th insurd woman or th dath of th child, if satisfid about such dath issu to such insurd woman or in cas of hr dath to hr nomin or lgal rprsntativ as th cas may b, fr of charg any such crtificat whn rasonably rquird by such insurd woman or hr nomin or lgal rprsntativ, as th cas may b, undr or for th purposs of th Act or any othr nactmnt or ths Rgulations : Providd that such Officr may issu a crtificat, as aforsaid, undr ths Rgulations, to or in rspct of an insurd woman who is or was not allottd to him or to th dispnsary, hospital, clinic or othr institution to which such officr is attachd, if such Officr is attnding th woman for prnatal car, for confinmnt, for miscarriag or for sicknss arising out of prgnancy, confinmnt, prmatur birth of child or miscarriag or in cas of dath, was attnding th dcasd insurd woman or th child at th tim of dath of th insurd woman or th child: Providd furthr that a crtificat of prgnancy, of xpctd confinmnt, or confinmnt or miscarriag rquird undr ths Rgulations may b issud by a rgistrd midwif which shall b accptd by th Corporation on countr-signaturs by th Insuranc Mdical Officr: Providd that such officr may issu a crtificat of prgnancy, xpctd confinmnt or confinmnt undr ths rgulations to an insurd woman who is not allottd to him or to th dispnsary, hospital, clinic or othr institution to which such officr is attachd, if such officr is attnding th woman for prnatal car or for confinmnt: Providd furthr that a crtificat of prgnancy, of xpctd confinmnt or of confinmnt rquird undr ths rgulations may b issud by a rgistrd midwif which shall b accptd by th Corporation on countr signatur by th Insuranc Mdical Officr. Obligations of Insuranc Mdical Officr. 95. Nothing in ths rgulations shall rliv an Insuranc Mdical Officr to whom an insurd woman has bn allottd, or an Insuranc Mdical Officr attachd to th dispnsary, hospital, clinic or othr institution to which an insurd woman is allottd of th obligation to xamin and if in hr opinion th condition of th woman so justifis, issu fr of charg a crtificat of mrgncy, of xpctd confinmnt, or confinmnt or miscarriag or of sicknss arising out of prgnancy, confinmnt, prmatur birth of a child or miscarriag during any priod in which such insurd woman is obtaining tratmnt or attndanc from any othr prson or from any othr hospital or institution.
94[MEDICAL BENEFIT TO FAMILIES] Mdical bnfit to familis of insurd prsons. 95A. (1) Mdical bnfit may b xtndd to th familis of insurd prsons from such dat as th Corporation may, in consultation with Stat Govrnmnt, notify. (2) Th family of an insurd prson shall bcom ntitld to mdical bnfit 95[from th day th insurd prson himslf] bcoms ntitld to mdical bnfit and shall continu to b so ntitld so long as th insurd prson is ntitld to rciv mdical bnfit for himslf 96[or in th cas of dath of th insurd prson till such dat up to which th insurd prson would hav rmaind ntitld to mdical car, had h survivd]. (3) Th natur and scal of mdical bnfit to which th family of an insurd prson shall b ntitld shall b such as may b spcifid by th Stat Govrnmnt in consultation with th Corporation from tim to tim. 97[(4) Th appropriat offic shall arrang to add in Form 4, th particulars of th family ntitld to mdical bnfit.] (5) 98[***] FUNERAL 99[EXPENSES] Rport of dath of insurd prson. 95B. In cas of dath of an insurd prson (a) if th dath occurs at th plac of mploymnt, th mployr shall, and (b) if th dath occurs at any othr plac, th prson ntitld and intnding to claim funral 1[xpnss] shall, or (c) any othr prson prsnt at th tim of dath may, immdiatly rport th dath to th 55a[Branch] Offic of th dcasd insurd prson. Issu of dath crtificat. 95C. An Insuranc Mdical Officr attnding th insurd prson at th tim of dath or th Insuranc Mdical Officr who xamins th body aftr th dath or th Mdical Officr who attndd th insurd prson in a hospital or othr institution whr such insurd prson did, shall issu fr of charg a dath crtificat in Form 1a[13] to th prson ntitld and intnding to claim funral 1[xpnss]. Othr vidnc in liu of a crtificat. 95D. Th Corporation may accpt any othr vidnc in liu of a dath crtificat by Insuranc Mdical Officr if in its opinion, th circumstancs of any particular cas so justify. Submission of claim for funral 1[xpnss]. 95E. (1) A claim to funral 1[xpnss] shall b submittd to th appropriat 55a[Branch] Offic by post or othrwis in Form 1b[22] by th claimant ntitld undr th Act and in cas of a minor, by his guardian, and such claim shall b supportd by documnts proving: (i) th dath of th dcasd prson, (ii) that th prson claiming is th ldst surviving mmbr of th family of th dcasd insurd prson and incurrd th xpnditur ncssary for th funral of th dcasd, or (iii) in cas th claimant is othr than th ldst surviving mmbr of th family: (a) that th dcasd insurd prson did not hav a family or that th dcasd insurd prson was not living with his family at th tim of his dath; and (b) that th claimant actually incurrd th xpnditur claimd on th funral of th dcasd insurd prson :
Providd that whr th appropriat offic is satisfid about th bona fids of th applicant or about th truth of th facts rlating to any of th mattrs mntiond abov, on or mor of th documnts may b dispnsd with. (2) Th following may b accptd as proof for purposs of clauss (ii) and (iii) of sub-rgulation (1) of this rgulation A dclaration of th claimant duly countrsignd by (i) an officr of th Rvnu, Judicial or Magistrial Dpartmnts of Govrnmnt; or (ii) a Municipal Commissionr; or (iii) a Workmn s Compnsation Commissionr; or (iv) th Had of Gram Panchayat undr th official sal of th Panchayat; or (v) th mployrs of th dcasd insurd prson; or (vi) any othr vidnc or dclaration accptabl to th appropriat offic in th circumstancs of a particular cas. CHAPTER IV MISCELLANEOUS Authority for dtrmining bnfits. 96. Th authority for dtrmining for purposs of sub-sction (2) of sction 70 of th Act, th valu of bnfits othr than cash paymnt shall b th Mdical Commissionr of th Corporation. 2[Rimbursmnt of xpnss incurrd in rspct of Mdical tratmnt. 96A. Claims for rimbursmnt of xpnss incurrd in rspct of mdical tratmnt of insurd prson and (whr such mdical bnfit is xtndd to his family) his family may b accptd in circumstancs and subjct to such conditions as th Corporation may by gnral or spcial ordr spcify.] Discontinuation or rduction of bnfits. 97. An mployr may discontinu or rduc bnfits payabl to his mploys undr conditions of thir srvic which ar similar to th bnfits confrrd by th Act to th xtnt spcifid blow, namly (a) from th dat of th commncmnt of th first bnfit priod following th appointd day for his factory or stablishmnt (i) sick lav on half pay to th full xtnt; (ii) such proportion of any combind gnral purposs and sick lav on half pay as may b assignd as sick lav but in any cas not xcding 50 pr cnt of such combind lav; (b) any matrnity bnfits grantd to womn mploys to th xtnt to which such womn mploys may bcom ntitld to th matrnity bnfit undr th Act: Providd that whr an mploy avails himslf of any lav from th mployr for sicknss, matrnity or tmporary disablmnt, th mployr shall b ntitld to dduct from th lav salary of th mploy th amount of bnfit to which h may b ntitld undr th Act for th corrsponding priod. Discharg, tc., of mploy undr crtain conditions. 98. If th conditions of srvic of any mploy so allow, an mployr may discharg or rduc on du notic an mploy
(i) who has bn in rcipt of disablmnt bnfit for tmporary disablmnt, aftr h has bn in rcipt of such bnfit for a continuous priod of six months or mor; (ii) who has bn undr mdical tratmnt for sicknss or has bn absnt from work as a rsult of illnss 3[***] duly crtifid in accordanc with ths rgulations to aris out of th prgnancy or confinmnt rndring th mploy unfit for work, aftr th mploy has bn undr such tratmnt or has bn absnt from work for a continuous priod of six months or mor; 4[(iii) who has bn undr mdical tratmnt for any of th following disass, duly crtifid in accordanc with ths rgulations, aftr th mploy has bn undr such tratmnt for a continuous priod of 18 months or mor, notwithstanding provisions of clauss (i) and (ii): 5-7[I. Infctious Disass 1. Tubrculosis 2. Lprosy 3. Chronic Empyma 4. Bronchiactsis 5. Intrstitial Lung Disas 6. AIDS II. Noplasms 7. Malignant Disass DESEASES III. Endocrin Nutritional and Mtabolic Disordrs 8. Diabts mllitus with prolifrativ rtinopathy/dibtic foot/nphropathy IV. Disordrs of Nrvous Systm 9. Monoplgia 10. Hmiplgia 11. Paraplgia 12. Hmiparsis 13. Intracranial Spac Occupying Lsion 14. Parkinson s disas 15. Spinal Cord Comprssion 16. Myasthnia Gravis/Nuromuscular Dystrophis V. Disass of Ey 17. Immatur Cataract with vision 6/6 or lss 18. Dtachmnt of Rtina 19. Glaucoma VI. Disass of Cardiovascular Systm 20. Coronary Artry Disas (a) Unstabl Angina (b) Myocardial infraction with jction lss than 45 pr cnt 21. Congstiv Hart Failur: Lft Right 22. Cardiac Valvular Disass with failur/complications 23. Cardiomyopathis 24. Hart Disas with Surgical Intrvntion along with complications VII. Chst Disass
25. Chronic Obstructiv Lung Disas (COPD) with congstiv hart failur (Cor Pulmonal) VIII. Disass of th Digstiv Systm 26. Cirrhosis of livr with ascitis/chronic activ hpatitis IX. Orthopadic Disass 27. Dislocation of vrtbra/prolaps of intrvrtbral disc 28. Non-union or dlayd union of fractur 29. Post Traumatic Surgical amputation of lowr xtrmity 30. Compound fractur with chronic ostomylitis X. Psychoss 31. Sub-groups undr this ar listd for clarification XI. Othrs (a) Schizophrnia (b) Endognous dprssion (c) Manic Dprssiv psychosis (MDF) (d) Dmntia 32. Mor than 20 pr cnt burns with infction/complication 33. Chronic Rnal Failur. 34. Rynaud s disas/burgr s disas.] Suspnsion of sicknss or tmporary disablmnt bnfit. 99. Sicknss bnfit of disablmnt bnfit for tmporary disablmnt may b suspndd, if a prson who is in rcipt of such bnfit fails to comply with any of th rquirmnts of sction 64 of th Act, and such suspnsion shall b for such numbr of days as may b dcidd by th authority authorisd by th Dirctor-Gnral in this bhalf. 8[Sicknss or tmporary disablmnt bnfit during strik. 99A. No prson shall b ntitld to sicknss bnfit or disablmnt bnfit for tmporary disablmnt on any day on which h rmains on strik xcpt in th following circumstancs: (i) if a prson is rciving mdical tratmnt and attndanc as an indoor patint in any Employs Stat Insuranc Hospital or a hospital rcognisd by th Employs Stat Insuranc Corporation for such tratmnt; or (ii) if a prson is ntitld to rciv xtndd sicknss bnfit for any of th disass for which such bnfit is admissibl; or (iii) if a prson is in rcipt of sicknss bnfit or disablmnt bnfit for tmporary disablmnt immdiatly prcding th dat of commncmnt of notic of th strik givn by th mploys Union(s) to th managmnt of th factory/stablishmnt; or 9[(iv) if an insurd prson/insurd woman has undrgon opration on account of vasctomy/tubctomy, h/sh shall b ntitld to nhancd sicknss bnfit on any day on which h/sh rmains on lav during th priod of strik or rmains on lav, or on holiday for which h/sh rcivs wags.] Rlaxation. 100. Th Dirctor-Gnral may by spcial or gnral ordr rlax any rgulation undr such circumstancs and subjct to such conditions, as h may dm fit. 101. [***]
Crtain officrs to hav powrs of inspction. 102. Th Dirctor-Gnral, th Insuranc Commissionr, th Joint Insuranc Commissionr, a Dputy Insuranc Commissionr, a Rgional Dirctor, a Dputy Rgional Dirctor, 10[an Assistant Insuranc Commissionr, an Assistant Rgional Dirctor] and a 10a[Branch] Offic Managr shall hav all th powrs of an Inspctor spcifid in sub-sction (2) of sction 45 of th Act. In addition to th officrs mntiond abov, th Dirctor-Gnral may, by a writtn ordr, confr upon any mploy of th Corporation or any Govrnmnt officr th powrs of an Inspctor for such priod or priods as h may think fit. 11[Inspction book. 102A. (i) Evry principal mployr shall maintain a bound inspction book and shall b rsponsibl for its production, on dmand by an Inspctor or any othr Officr of th Corporation duly authorisd to xrcis th powrs of an Inspctor irrspctiv of th fact whthr th principal mployr is prsnt in th factory or stablishmnt or not during th inspction. (ii) A not of all irrgularitis and illgalitis discovrd at th tim of inspction indicating thrin th action, if any, proposd to b takn against th principal mployr togthr with th ordrs for thir rmdy or rmoval passd by an Inspctor or any othr officr of th Corporation duly authorisd to xrcis th powrs of an Inspctor, shall b snt to th principal mployr who shall ntr th not and ordrs in th inspction book. (iii) Evry principal mployr shall prsrv th inspction book maintaind undr this rgulation, aftr it is filld for a priod of 5 yars from th dat of th last ntry thrin.] Mdical bnfit during disablmnt. 103. A prson who is in rcipt of disablmnt bnfit shall b ntitld to mdical bnfit whil h is in rcipt of such bnfit: Providd that aftr th disablmnt has bn dclard as a prmannt disablmnt, th prson shall not b ntitld to mdical bnfit, if h is not othrwis ntitld to such bnfit, xcpt, in rspct of any mdical tratmnt which may b rndrd ncssary on account of th mploymnt injury from which th disablmnt rsultd. 12[Mdical bnfit aftr contribution cass to b payabl. 103A. (1) A prson on bcoming an insurd prson for th first tim shall b ntitld to mdical bnfit for a priod of 13[3 months] providd that whr such a prson continus for 13[3 months] or mor to b an mploy of a factory or stablishmnt to which th Act applis, h shall b ntitld to mdical bnfit till th bginning of th corrsponding bnfit priod. 14[(2) Th prson in rspct of whom contributions hav bn paid in a contribution priod for not lss than svnty-ight days in th said contribution priod shall b ntitld to mdical bnfit till th nd of th corrsponding bnfit priod: Providd that in cas of a prson who bcoms an mploy within th maning of th Act, for th first tim, and for whom a shortr contribution priod of lss than 156 days is availabl, h shall b ntitld to mdical bnfit till th nd of th corrsponding bnfit priod if th contributions in rspct of him wr payabl for not lss than half th numbr of days availabl for working in such contribution priod : Providd furthr that whr a prson suffring from any of th following disass, bfor th commncmnt of th spll of sicknss in which any such disas was diagnosd bing in continuous srvic for a priod of two yars or mor or whr h did not hav two yars continuous srvic but by virtu of rlaxation grantd by th authority comptnt in this bhalf, th insurd prson qualifis to claim xtndd sicknss bnfit, h shall b ntitld to mdical bnfit till th nd of th rlvant xtndd bnfit priod: 14a[I. Infctious Disass 1. Tubrculosis 2. Lprosy
3. Chronic Empyma 4. Bronchiactsis 5. Intrstitial Lung Disas 6. AIDS II. Noplasms 7. Malignant Disass III. Endocrin Nutritional and Mtabolic Disordrs 8. Diabts mllitus with prolifrativ rtinopathy/dibtic foot/nphropathy IV. Disordrs of Nrvous Systm 9. Monoplgia 10. Hmiplgia 11. Paraplgia 12. Hmiparsis 13. Intracranial Spac Occupying Lsion 14. Parkinson s disas 15. Spinal Cord Comprssion 16. Myasthnia Gravis/Nuromuscular Dystrophis V. Disass of Ey 17. Immatur Cataract with vision 6/6 or lss 18. Dtachmnt of Rtina 19. Glaucoma VI. Disass of Cardiovascular Systm 20. Coronary Artry Disas (a) Unstabl Angina (b) Myocardial infraction with jction lss than 45 pr cnt 21. Congstiv Hart Failur: Lft Right 22. Cardiac Valvular Disass with failur/complications 23. Cardiomyopathis 24. Hart Disas with Surgical Intrvntion along with complications VII. Chst Disass 25. Chronic Obstructiv Lung Disas (COPD) with congstiv hart failur (Cor Pulmonal) VIII. Disass of th Digstiv Systm 26. Cirrhosis of livr with ascitis/chronic activ hpatitis IX. Orthopadic Disass 27. Dislocation of vrtbra/prolaps of intrvrtbral disc 28. Non-union or dlayd union of fractur 29. Post Traumatic Surgical amputation of lowr xtrmity 30. Compound fractur with chronic ostomylitis X. Psychoss 31. Sub-groups undr this ar listd for clarification (a) Schizophrnia (b) Endognous dprssion
XI. Othrs (c) Manic Dprssiv psychosis (MDF) (d) Dmntia 32. Mor than 20 pr cnt burns with infction/complication 33. Chronic Rnal Failur. 34. Rynaud s disas/burgr s disas.] 15[(3) An insurd prson, whos titl to mdical bnfit has casd undr this rgulation shall again b ntitld to mdical bnfit from th dat of his r-mploymnt as an mploy undr th Act by a factory or stablishmnt to which th Act applis, if h producs a crtificat from th mployr in th form which may b spcifid by th Dirctor-Gnral for th purpos. Such an insurd prson shall, unlss h is covrd by sub-rgulation (2), b ntitld to mdical bnfit till th commncmnt of th bnfit priod corrsponding to th contribution priod in which h is r-mployd. 16[(4)] An mployr shall, on dmand, issu th crtificat rfrrd to in 17[sub-rgulation (3)] to an mploy who has bn mployd by him aftr cssation of his prvious insurabl mploymnt.] 18[Mdical bnfit to insurd prson who cass to b in insurabl mploymnt on account of prmannt disablmnt. 103B. (1) An insurd prson who cass to b in insurabl mploymnt on account of prmannt disablmnt causd du to mploymnt injury shall continu to rciv mdical bnfit for himslf and his/hr spous till th dat on which h would hav vacatd th mploymnt on attaining th ag of suprannuation had h not sustaind such prmannt disablmnt, if h producs a crtificat from th mployr/a dclaration in th form which may b spcifid by th Dirctor-Gnral for th purpos. (2) Mdical bnfit to rtird insurd prsons - An insurd prson who has attaind th ag of suprannuation shall b ligibl to rciv mdical bnfit for himslf and his/hr spous, if h producs a crtificat from th mployr in th form which may b spcifid by th Dirctor- Gnral for th purpos. (3) An mployr shall, on dmand, issu th crtificat as rfrrd to in sub-rgulations (1) and (2) to an mploy who had bn mployd by him.] Production of documnt for mdical bnfit. 104. A prson intnding to claim mdical bnfit, and who is othrwis ntitld to such bnfit, shall produc his Idntity Card or such othr documnt as may hav bn issud in liu throf at th tim of claiming such bnfit if dmandd by th Insuranc Mdical Officr and if h fails to do so mdical bnfit may b rfusd to him. Furthr crtificats. 105. Whr any qustion ariss as to th corrctnss of any crtificat by virtu of which an insurd prson claims, or is ntitld to, any bnfit undr th Acts, h shall, on bing so rquird in writing or othrwis by th appropriat offic submit himslf, with a viw to obtaining a furthr crtificat, to mdical xamination by such mdical authority as th Corporation may appoint in this bhalf. 19[If th furthr crtificat spcifis th dat on which th insurd prson is or will b fit to rsum work, any crtificat which is or has bn issud by th Insuranc Mdical Officr for th sam spll of incapacity shall, to th xtnt to which it rlats to any priod aftr and including th said dat on th furthr crtificat, b dmd not to hav bn issud in accordanc with ths Rgulations and such furthr crtificat shall, notwithstanding anything containd in ths rgulations, b dmd to b a final crtificat issud undr rgulations 58 and 60.] Notwithstanding anything containd in ths Rgulations, such furthr crtificat insofar as it rlats to sicknss or tmporary disablmnt, may b issud at such intrval and in rspct of such priods as may b spcifid by such mdical authority.
Chang of circumstancs to b notifid. 106. Evry prson to whom any bnfit is payabl undr th Act shall, as soon as may b practicabl, notify th appropriat offic of any chang of circumstanc which h may b xpctd to know and which might affct th continuanc of his right to rcipt of such bnfit. 20[Crtificat in rspct of a prson claiming prmannt disablmnt bnfit. 107. Evry prson whos claim for any prmannt disablmnt bnfit has bn admittd shall submit at six-monthly intrvals, with th claim for Dcmbr and Jun vry yar, a crtificat in Form 20a[23] attstd by such authority or prsons and in such mannr as may b spcifid by th Dirctor-Gnral. 21[Dclaration by and crtificat in rspct of a prson claiming dpndants bnfit. 107A. Evry prson whos claim for any dpndants bnfit has bn admittd shall submit at six monthly intrvals, with th claim for Dcmbr and Jun vry yar, a dclaration and a crtificat in Form 21a[23] attstd by such authority or prson and in such mannr as may b spcifid by th Dirctor-Gnral. Prsonal attndanc of a prson claiming prmannt disablmnt bnfit or dpndnts bnfit. 107B. In th cas of claimant for prmannt disablmnt bnfit or dpndants bnfit, th appropriat 10a[Branch] Managr may rquir prsonal attndanc and du idntification of any claimant, othr than a prson incapacitatd by bodily illnss or infirmity or a purdanashin lady at th appropriat 21b[Branch] Offic or at any othr offic of th Corporation providd that such apparanc shall not b rquird mor frquntly than onc in vry six months.] Actuarial prsnt valu of th priodical paymnts. 108. 22[* * *] 23[Submission of additional information by mployr or insurd prson. 109. Th mployr or insurd prson, as th cas may b, shall, on dmand from th appropriat offic, submit information in such form as may b spcifid by th Dirctor-Gnral.]
24FORM 01 [S Rgulation 10B] EMPLOYERS' REGISTRATION FORM (Rgulation 10-B) *Employr's Cod No. 1. Nam of th Factory/Establishmnt :... 2. Complt postal addrss of th Factory/ :... Establishmnt...PIN...... 3. (a) Tlphon No., if (b) Fax No if any... any... (c) E-mail addrss, if any... 4. Location of Factory/Establishmnt : (a) Stat...... (b) (c) District...... Municipality/Ward...... (d) Nam of Town/Rvnu Villag... (Taluk/Tahsil)... () Polic Station... (f) Rvnu Dmarcation/Hudbast No.... 5. (a) Whthr th building/prmiss of :... factory/stablishmnt is ownd or hird (b) If hird or thr is a chang in th nam of unit/ownrship, plas indicat: (i) ESI Cod No., if covrd arlir... (ii) Dat from which arlir factory/ stablishmnt closd down (iii) Trms and conditions undr which proprty acquird/takn on las (Enclos copy of agrmnt/rlvant dd)...... 6. (a) Dtails of Bank A/c: : (b) Nam of Bank and Branch (a) Account... (b) Account... (c) Account... No. No. No. (i)... (ii)... (iii)... 7. (a) Incom Tax PAN/GIR No. :... (b) Incom Tax Ward/Circl/Ara...
8. Exact natur of work/businss carrid on :... 9. Dat of commncmnt of Factory/ :... Establishmnt 10. (a) Whthr rgistrd undr :... Factoris/Shop and Establishmnt/Othr Act (Plas spcify) (b) Factory Licnc No./Trad Licnc : Licnc No. Dat Licncing Authority No./ Catring Establishmnt Licnc No./Shop Establishmnt Rgistration No./Licnc No. undr Cinmatography Act tc. (c) Plas giv whichvr is applicabl : No. Dat Issuing Authority (i) Commrcial Tax No. (ii) Stat Sals Tax No. (iii) Cntral Sals Tax No. (iv) Any othr Tax No. (i) (ii) (iii) (iv) (d) Maximum numbr of prsons that :... can b mployd on any on day, as pr licnc 11. (a) Whthr powr is usd for :... manufacturing procss as pr Sction 2(K) of th Factory Act. If so, sinc whn (b) In cas of factory whthr licnc :... issud undr Sction 2(m)(i) or 2(m)(ii) of th Factoris Act, 1948 (c) Powr connction No. No. Sanctiond Issuing Authority powr load 12. (a) Whthr it is Public or Privat. Ltd. :... Company/Partnrship/Propritorshi p/co-oprativ Socity/Ownrship (Attach copy of Mmorandum and Articls of Association/Partnrship Dd/Rsolution) (b) Giv nam, prsnt and prmannt rsidntial addrss of prsnt Propritor/Managing Dirctors, Dirctor/Managing Partnrs, Partnrs/Scrtary of th Cooprativ Socity. 13. Addrss(s) of th Rgistrd Offic/Had Offic/ Branch Offic/Sals Offic/Administrativ Offic/ othr offics, if any, with numbr of mploys attachd with ach such offic and prson rsponsibl for th offic Nam (i) (ii) (iii) (iv) (v) (vi) (vii) : Addrss as on dat No. of mploy Dsignation Addrss Phon No./ Fax No. Function Prson rsponsibl for day-to-day functioning of th offic (Giv dtails on a sparat sht, if rquird) 14. (a) Whthr any work/businss carrid :... out through contractor/immdiat mployr (b) If ys, giv natur of such :...
work/businss 15. (a) EPF Cod No. : No. Issuing Authority (If covrd undr EPF Act) 16. Total numbr of mploys mployd for wags dirctly and through immdiat mployrs on th dat of application (Whthr manual/clrical/suprvisor, connctd with th administration or purchas of raw matrials or distribution or sal of product/srvic, whthr prmannt or tmporary) As on dat Total No. of mploys No. of mploys drawing wags Rs 7500 or lss Mal Fmal Total Mal Fmal Total Employd dirctly by th Principal Employr Through Immdiat mployr/ Contractor Total 17. Total wags paid in th prcding month To mploys mployd dirctly by th Principal mployr Total wags Wags paid to mploys drawing wags Rs 7500 or lss To mploys mployd through immdiat mployr/contractor 18. Giv first dat sinc whn 10/20** or... mor covrabl mploys undr ESI Act wr mployd for wags I hrby dclar that th statmnt givn abov is corrct to th bst of my knowldg and blif. I also undrtak to intimat changs, if any, promptly to th Rgional Offic/Sub-Rgional Offic. ESI Corporation is soon as such changs tak plac Dat Nam and Signatur... Plac Dsignation with sal... [Should b signd by principal mployr u/s. 2(17) of ESI Act] * Plas mntion th Employr's Cod No. if prviously allottd in cas th factory/stablishmnt was covrd undr th ESI Act. ** Scor out whichvr is not applicabl. In cas of factory/an stablishmnt using powr in th manufacturing procss th numbr applicabl is 10 prsons or mor. In th cas of a factory not using powr or an stablishmnt ngagd in manufacturing procss without using powr or any othr stablishmnt, th numbr applicabl is 20 or mor prsons. INSTRUCTIONS Not 1. Plas nclos photocopy of th following dds/agrmnts/documnts/crtificat: (a) Rgistration Crtificat/Licnc issud undr Shops and Establishmnts Act or Factoris Act. (b) Latst Rnt Bill of th prmiss you ar occupying indicating th capacity in which th prmiss is occupid, if applicabl. (c) Latst Building Tax/Proprty Tax rcipt (Zrox). (d) Mmorandum and Articls of Association/Partnrship Dd/Trust Dd. () Zrox copy of crtificat of commncmnt of production and/or Rgistration No. of CST/ST. Not 2. "Powr" shall hav th maning assignd to it in th Factoris Act, 1948 which is as undr:
'Powr' mans lctrical nrgy, or any othr form of nrgy which is mchanically transmittd and is not gnratd by human or animal agncy. Not 3. Manufacturing procss as dfind in Sction 2(k) in Factoris Act is as undr: 'Manufacturing procss' mans any procss for (i) making, altring, rpairing, ornamnting, finishing, packing, oiling, washing, claning, braking up, dmolishing, or othrwis trating or adapting any articl or substanc with a viw to its us, sal, transport, dlivry or disposal; (ii) pumping oil, watr, swag or any othr substanc; (iii) gnrating, transforming or transmitting powr; (iv) composing typs for printing, printing by lttr prss, lithography photogravur or othr similar procss or book binding; (v) constructing, rconstructing, rpairing, rfitting, finishing or braking up ships or vssls; (vi) prsrving or storing any articl is cold storag. Not 4. "Immdiat Employr" in rlating to mploys mployd by or through him, mans a prson who has undrtakn th xcution, on th prmiss of th factory or an stablishmnt to which this Act applis or undr th suprvision of th principal mployr or his agnt, of th whol or any part of any work which is ordinarily part of th work of th factory or stablishmnt of th principal mployr or is prliminary to th work carrid on in, or incidntal to th purpos of, any such factory or stablishmnt and includs a prson by whom th srvics of an mploy who has ntrd into a contract of srvic with him ar tmporarily lnt or lt on hir to th principal mployr and includs a contractor. Not 5. "Principal Employr" mans (a) In a factory th ownr or occupir of th factory and includs th managing agnt of such ownr or occupir, th lgal rprsntativ of a dcasd ownr or occupir and whr a prson has bn namd as th managr of th factory undr th Factoris Act, 1948, th prson so namd; (b) In any stablishmnt undr th control of any dpartmnt of any Govrnmnt, in India th authority appointd by such Govrnmnt in this bhalf or whr no authority is so appointd, th had of th Dpartmnt; (c) In any othr stablishmnt, any prson rsponsibl for th suprvision and control of th stablishmnt. Not 6. "Occupir" of a factory/stablishmnt mans th prson who has ultimat control ovr th affairs of th factory/stablishmnt and whn th said affairs ar ntrustd to a managing agnt shall b th occupir of th factory/stablishmnt Not 7. "Employs" mans any prson mployd for wags in or in connction with th work of a factory or an stablishmnt to which this Act applis, and (i) who is dirctly mployd by th principal mployr on any work of, or incidntal or prliminary to or connctd with th work of, th factory or stablishmnt whthr such work is don by th mploy in th factory or stablishmnt or lswhr; or (ii) who is mployd by or through an immdiat mployr on th prmiss of th factory or stablishmnt or undr th suprvision of th principal mployr or his agnt on work which is ordinarily part of th work of th factory or stablishmnt or which is prliminary to b carrid on in or incidntal to th purpos of th factory or stablishmnt; or (iii) whos srvics ar tmporarily lnt or lt on hir to th principal mployr by th prson with whom th prson whos srvics ar so lnt or lt on hir has ntrd into a contact of srvic; and includs any prson mployd for wags on any work connctd with th administration of th factory or stablishmnt or any part dpartmnt or branch throf with th purchas of raw matrials for, or th distribution or sal of th products of, th factory or stablishmnt; [or any prson ngagd as an apprntic, not bing an apprntic ngagd undr th Apprntics Act, 1961 (52 of 1961), or undr th standing ordrs of th stablishmnt, but dos not includ] (a) Any mmbr of th Indian Naval, Military or Air Forc; or
(b) Any prson so mployd whos wags xcluding rmunration for ovrtim work xcds such wags as may b prscribd by th Cntral Govrnmnt, a month: Providd that an mploy whos wags xcluding rmunration for ovrtim work xcds such wags as may b prscribd by th Cntral Govrnmnt, a month at any tim aftr and not bfor th bginning of th contribution priod, shall continu to b an mploy until th nd of that priod. Not 8. "Wags" mans all rmunration paid or payabl in cash to an mploy, if th trms of th contract of mploymnt, xprss or implid, wr fulfilld and includs any paymnt to an mploy in rspct of any priod of authorizd lav, lock-out, strik which is not illgal or layoff and othr additional rmunration, if any, paid at intrvals not xcding two months, but dos not includ: (a) any contribution paid by th mployr to any pnsion fund or providnt fund, or undr this Act; (b) any travlling allowanc or th valu of any travlling concssion; (c) any sum paid to th prson mployd to dfray spcial xpnss ntaild on him by th natur of his mploymnt; or (d) any gratuity payabl on discharg.
24a FORM-01(A) FORM OF ANNUAL INFORMATION ON FACTORY/ ESTABLISHMENT COVERED UNDER ESI ACT (Rgulation 10-C) *Employr's Cod No. 1. Nam of th Factory/Establishmnt :. 2. Complt postal addrss of th : Factory/ Establishmnt.PIN. 3. (a) Tlphon No., if any (b) Fax No. if any. (c) E-mail addrss, if any (d) Nam of Town/Rvnu Villag (Taluk/Tahsil) () Polic Station (f) Rvnu Dmarcation/Hudbast No 4. Location of Factory/Establishmnt : (a) Stat.. (b) District (c) Municipality / Ward 5. (a) Dtails of Bank A/c: :(b) Nam of Bank and Branch (a) Account No (i).. (b) Account No (c) Account No 6.(a) Incom Tax PAN/GIR No. (b) Incom Tax Ward/Circl/Ara (ii)... (iii).. :.. 7. (a) In cas of factory whthr licnc :... issud undr sction 2(m)(i) or 2(m)(ii) of th Factoris Act, 1948 (b) Powr Connction No. No. Sanctiond powr load Issuing Authority 8. (a) Whthr it is Public or Privat Ltd. :... Company/Partnrship/Propritorshi p/co-oprativ Socity/Ownrship (Attach copy of Mmorandum and Articls of Association/Partnrship Dd/Rsolution) (b) Giv nam, prsnt and prmannt rsidntial addrss of prsnt (i) Propritor/ Managing Dirctors, (ii) Dirctor/Managing Partnrs, (iii) Partnrs/Scrtary of th Cooprativ (iv) Socity (v) (vi) (vii) 9. Addrss(s) of th Rgistrd Offic/Had Offic/Branch Offic/Sals Offic/Administrativ Offic/othr offics, if any, with numbr of mploys attachd with ach such offic and prson rsponsibl for th offic Nam Dsignation Addrss Addrss as on dat No. of mploy Phon No./Fax No. Function Prson rsponsibl for day-today functioning of th offic Giv dtails on a sparat sht, if rquird)
10.(a) Whthr any work/businss :.. carrid out through contractor/immdiat mployr (b)if ys, giv natur of such :.. work/businss I hrby dclar that th statmnt givn abov is corrct to th bst of my knowldg and blif. I also undrtak to intimat changs, if any, promptly to th Rgional Offic/Sub-Rgional Offic, ESI Corporation as soon as such changs tak plac Dat Plac Nam and Signatur Dsignation with sal. [Should b signd by principal mployr u/s. 2(17) of ESI Act]
25-27FORM 1 DECLARATION FORM To b filld by mploy aftr rading instructions ovrlaf. Two postcard siz photographs to b attachd with th form. Th form is fr of cost. (A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS 1. Insuranc No. 9. Employr's Cod No. 2. Nam (in block lttrs) 10. Dat of Appointmnt Day Month Yar 3. Fathr's/Husband's nam 11. Nam and Addrss of th Employr 4. Dat of birth Day Month Yar 5. Marital Status M/U/W 6. Sx M/F 7. Prsnt Addrss 8. Prmannt Addrss 12. In cas of any prvious mploymnt plas fill up th dtails as undr:-.. (a) Prvious Ins. No... (b) Employr's Cod No... (c) Nam and Addrss of Employr Pin cod Pin cod Tlphon No./-mail addrss Tlphon No./-mail addrss Branch Offic Dispnsary Tlphon No./-mail addrss (C). Dtails of Nomin u/s. 71 of ESI Act 1948/Rul 56(2) of ESI (Cntral) Ruls, 1950 for paymnt of cash bnfit in th vnt of dath Nam Rlationship Addrss I hrby dclar that th particulars givn by m ar corrct to th bst of my knowldg and blif. I undrtak to intimat th Corporation any changs in th mmbrship of my family within 15 days of such chang. Countr-signatur by th mployr Signatur/T.I, of IP
Signatur with sal (D) FAMILY PARTICULARS OF INSURED PERSON Sl. No. 1. 2. 3. 4. 5. 6. 7. Nam Dat of Birth/Ag as on dat of filling form Rlationship with th Employ Whthr rsiding with him/hr. Say If 'No' Stat plac of Rsidnc Ys No Town Stat ESI Corporation Tmporary Idntity Card Valid for 3 months form th dat of appointmnt Nam Ins. No. Dat of appointmnt Branch Offic Dispnsary Employ's Cod No. and Addrss (Spac for photograph) Validity Signatur/T.I of I.P. Signatur of B.M. with sal Datd: INSTRUCTIONS 1. Submission of Form-1 is govrnd by Rgulations 11 and 12 of ESI (Gnral) Rgulations, 1950. 2. "Family" mans all or any of th following rlativs of an Insurd Prson, namly:- (i) a spous; (ii) a minor lgitimat or adoptd child dpndant upon th I.P.; (iii) a child who is,wholly dpndant on th arnings of th I.P. and who is (a) rciving ducation, till h or sh attains th ag of 21 yars (b) an unmarrid daughtr; (iv) a child who is infirm by rason of any
physical or mntal abnormality or injury and is wholly dpndant on th arnings of th I.P. so long as th infirmity continus; (v) dpndant parnts (Plas s Sction 2 Claus 11 of th ESI Act, 1948 for dtails). 3. Idntity Card is not-transfrabl. 4. Loss of Idntity Card b rportd to Employr/Branch Managr immdiatly. 5. Submission of fals information attracts pnal action undr Sction 84 of ESI Act, 1948. 6. This form duly filld in must rach th concrnd Branch Offic within 10 days of appointmnt of an Employ. Dlay attracts pnal action undr Sction 85 of th Act against mployr. 7. As an insurd prson you and your dpndnt family mmbrs ar ntitld to full mdical car from today itslf. Th othr bnfits in cash includ (a) Sicknss Bnfit (2) Tmporary Disablmnt bnfit (3) Prmannt disablmnt bnfit (4) Dpndnts bnfit and (5) Matrnity bnfit (in cas of womn mploys) subjct to fulfillmnt of contributory conditions. 8. For mor dtails plas contact wbsit of ESIC at www.sic.org.in or contact Rgional Offic or Branch Offic. FOR BRANCH OFFICE USE ONLY 1. Dat of allotmnt of Ins. No.:.. Dat of issu of T.I.C. : :.. 3. Nam/No, of Disp. : :.. 4. Whthr rciprocal mdical arrangmnts involvd. If ys, plas indicat: :.. Signatur of Branch Managr Sl. No. Nam Dat of Birth/Ag as on dat of filing form Rlationship with th Employ Whthr rsiding with him/hr. Say If 'No' Stat plac of Rsidnc Ys No Town Stat 1. 2. 3. 4. 5. 6. 7.
28[FORM 1A [Rgulation 15A] FAMILY DECLARATION FORM Nam of th insurd prson... Insuranc... Srial No. Nam Dat of birth Rlationship with insurd prson Numbr 29[Whthr rsiding with him/hr or not] I hrby dclar that th particulars abov hav bn givn by m and ar tru to th bst of my knowldg and blif. I also undrtak to intimat to th Corporation any changs in th mmbrship of my family within 15 days of such changs having occurrd. Signatur/Thumb-imprssion of th insurd prson Dat... Countrsignd... Dat... Dsignation... Nam, Addrss and Cod No. of Employr... 30[Not - According to sction 2, claus (11) of th Employs Stat Insuranc Act, 1948, family mans all or any of th following rlativs of an insurd prson, namly, (i) a spous; (ii) a minor lgitimat or adoptd child dpndnt upon th IP; (iii) a child who is wholly dpndnt on th arnings of th IP and who is - (a) rciving ducation, till h or sh attains th ag of 21 yars, (b) an unmarrid daughtr; (iv) a child who is infirm by rason of any physical or mntal abnormality or injury and is wholly dpndnt on th arnings of th IP, so long as th infirmity continus; (v) dpndnt parnts.] Nam of th Insurd Prson 31-32 REG. FORM-2 Addition/Dltion in Family Dclaration Form EMPLOYEES' STATE INSURANCE CORPORATION (Rgulation 15-B) Insuranc No. I dclar that th prson/prsons whos particulars ar givn blow has/hav now bcom/casd to b mmbr(s) of my family.* Sl. No. Nam Dat of birth Rason(s) for chang and dat Rlationship with th Insurd prson Whthr rsiding with hr/ him or not, stat If no, whr rsiding Ys No Distt. Stat Nam of IMP/Disp. attachd I hrby dclar that th particulars givn abov ar tru to th bst of my knowldg and blif. Ncssary changs may kindly b mad in my Dclaration Form submittd arlir.
Passport siz photographs of th mmbrs who ar addd to family is/ar nclosd. Plac Dat Particulars of th Employr: Nam:....... Addrss:... Cod No.... Signatur/thumb imprssion of th mploy Nam in Block Lttrs Countrsignatur of th mployr. Dsignation with Rubbr Stamp Not. "Family" mans all or any of th following rlativs of an Insurd Prson, namly: (i) a spous; (ii) a minor lgitimat or adoptd child dpndant upon th I.P.; (iii) a child who is wholly dpndant on th arnings of th I.P. and who is (a) rciving ducation, till h or sh attains th ag of 21 yars (b) an unmarrid daughtr; (iv) a child who is infirm by rason of any physical or mntal abnormality or injury and is wholly dpndant on th arnings of th I.P. so long as th infirmity continus; (v) dpndant parnts (Plas s Sction 2, Claus 11 of th ESI Act, 1948 for dtails). * Plas submit duly attstd copy of th Birth/Dath Crtificat.
FORM 2 [Rgulation 13] CONTRIBUTION CARD 34[***] Nam and addrss of th Factory or Establishmnt... Employr s Cod Numbr... FORM 3 [Rgulation 14] RETURN OF DECLARATION FORMS I snd hrwith th Dclaration Forms in rspct of th mploys mntiond blow. I hrby dclar that vry prson mployd as an mploy within th maning of sction 2(9) of th Employs Stat Insuranc Act, 1948, on...in this factory or stablishmnt and in rcipt of a rmunration not xcding 35[Rs. 7,500] (now Rs. 3,000) pr month has bn includd in this list (xcpting only thos in rspct of whom dclarations hav bn snt to th Corporation in th past). Plac... Dat... Signatur... Dsignation... Srial No. Nam of th mploy Distinguishing No. with th mployr, if any Fathr s or Husband s nam Insuranc No. allottd by th Corporation (to b ntrd at th Appropriat Offic) 1 2 3 4 5 Enclosurs: Signatur... Dsignation... Dclaration Forms... Continuation shts... INSURANCE NO. EX & STATUS NAME FATHER OR HUSBAND S NAME PRESENT ADDRESS 36[FORM 4 [Rgulations 17 & 95A] IDENTITY CARD EMPLOYER S CODE NO. YR. BTH. SET DATE OF ENTRY LOCAL OFFICE DISPENSARY IDENTIFICATION MARKS
EMPLOYMENT CHANGES DATE CODE NO. DATE CODE NO. PARTICULARS OF MEMBERS OF FAMILY S. NO. NAME DATE OF BIRTH RELATIONSHIP WITH I.P. IDENTIFICATION MARKS ATTESTATION BY I.M.O./I.M.P. Signatur or Thumb Imprssion of th I.P. (i) I.P. will b printd in full. (ii) Biggr column will b providd for idntification marks at th tim of printing. Issud by]
Insuranc No. 37[FORM 4A [Rgulation 95A] FAMILY IDENTITY CARD Nam of insurd prson... Sx... Son of/daughtr of/wif of... Addrss... Dispnsary... Particulars of mmbrs of family Srial No. Nam Dat of birth 1 2 3 4 5 6 Signatur or thumb imprssion of th insurd prson. Rlationship with th insurd prson Idntification Marks Prpard by]
FORM 5 [Rgulation 22] RECEIPT FOR CONTRIBUTION CARD 38[* * *] * Du Dat for submission: 12th May/11th Novmbr* 39REG. FORM-5 Nam of Branch Offic Employr's Cod No. Rturn of Contributions EMPLOYEES' STATE INSURANCE CORPORATION (Rgulation-26) Nam and Addrss of th factory or :. stablishmnt Particulars of th Principal Employr(s) (a) Nam :. (b) Dsignation :. (c) Rsidntial Addrss :. Contribution priod from to I furnish blow th dtails of th mployr's and mploy's shar of contributions in rspct of th undrmntiond insurd prsons. I hrby dclar that th rturn includs ach and vry mploy, mployd dirctly or through an immdiat mployr or in connction with th work of th factory/stablishmnt or any work connctd with th administration of th factory/stablishmnt or purchas of raw matrials, sal or distribution of finishd products tc. to whom th ESI Act, 1948 applis, in th contribution priod to which this rturn rlats and that th contributions in rspct of mployr's and mploy's shar hav bn corrctly paid in accordanc with th provisions of th Act and Rgulations. Dtails of Challans: Employs' Shar.. Employr's Shar... Total Contribution.. SI. No. Month Dat of Challan Amount Nam of th Bank and Branch 1. 2. 3. 4. 5. 6. Total amount paid: Rs.. Plac.. Signatur and Dsignation of th Employr Dat... (With Rubbr Stamp) Important Instructions: Information to b givn in "Rmarks Column (No. 9)" (i) If any I.P. is appointd for th first tim and/or lavs during th contribution priod indicat "A..(dat)" and/or "L (dat)" (ii) Plas indicat Insuranc Nos. in ascnding ordr. (iii) Figurs in Columns 4, 5 and 6 shall b in rspct of wag priods ndd during th contribution priod. (iv) Invariably strik totals of Columns 4, 5 and 6 of th Rturn. (v) No ovrwriting shall b mad. Any corrctions, if mad, should b signd by th mployr.
SI. No. Insuranc Numbr (vi) Evry pag of this Rturn should bar full signatur and rubbr stamp of th mployr. (vii) Daily wags in Column 7 of th rturn shall b calculatd by dividing figurs in Column 5 by figurs in Column 4 to two dcimal placs. For *CP nding 31st March, du dat is 12th May For CP nding 30th Sptmbr, du dat is 11th Novmbr EMPLOYEES' STATE INSURANCE CORPORATION Employr's Nam and Addrss Employr's Cod No.. Priod from. to. Nam of Insurd prson No. of days for which wags paid Total amount of wags paid (Rs) Employ's contribution dductd (Rs) Avrag Daily Wags (Rs) Whthr still continus working Rmarks* 1 2 3 4 5 6 7 8 9 TOTAL *Dat of appointmnt and laving th job may b givn in rmarks column Signatur of th Employr 1. Entitlmnt position markd. (FOR OFFICIAL USE) 2. Total of Col. 5 of Rturn chckd and found corrct/ corrct amount is indicatd.
3. Chckd th amount of Employr's/Employ's contribution paid which is in ordr/obsrvation mmo nclosd. U.D.C. Had Clrk Branch Officr Countrsignatu r..
40FORM 5-A Employs' Stat Insuranc Corporation (Rgulation 31 Scond Proviso) Statmnt of Advanc Paymnt of Contributions mad for th Contribution Priod ndd... Total contribution amounting to Rs... comprising of... Rs... as mployr's shar and Rs... as mploys' shar paid as undr: Sl. No. Dtails of Advanc Paymnt Amount Dtails of actual contribution paid Amount Balanc 1 2 3 4 5 6 1. Opning Balanc 2. Challan datd... 3. Challan datd... 4. Challan datd... 5. Challan datd... 6. Challan datd... 7. Challan datd... Total (i) Rs. P.... *April/Octobr......... *May/Novmbr......... *Jun/Dcmbr......... *July/January......... *August/Fbruary......... *Sptmbr/March......... Total (ii) Total du for contribution priod Total amount paid in Advanc Balanc Total (ii) should not b lss than total (i) at any tim *Strik out which is not applicabl Plac... Dat... Signatur... Dsignation... 41-42REG. FORM-6 Rgistr of Employs EMPLOYEES' STATE INSURANCE CORPORATION (Rgulation 32) Contribution Priod : From to. S I. Insura nc No. Nam of *Nam of Occupat ion Dpartm nt and If appointd or lft srvic Month.. No. Total Employ of amount s'
N o. th Insu rd Prs on dispn sary to which attach d shift, if any during th contribution priod, dat of appointmnt/l aving srvic days for whic h wag s paid / paya bl of wags paid/pay abl shar of contribu tion 1 2 3 3(A) 4 5 6 7 8 9 Total Employr' s shar Grant total Paid on Month.. Month.. Month.. No. of days for which wags paid/payab Total amount of wags paid/ Employs' shar of contributio n (Rs) No. of days for which wags paid/payab Total amount of wags paid/ Employs' shar of contributio n (Rs) No. of days for which wags paid/payab Total amount of wags paid/ Employs' shar of contributio n (Rs) l payabl (Rs) l payabl (Rs) l payabl (Rs) 10 11 12 13 14 15 16 17 18 Total Total Total Employrs' shar Employrs' shar Employrs' shar Grand Total Grand Total Grand Total Paid on Paid on Paid on Month.. No. of Total Employ days for amoun s' which t of shar of wags wags contrib paid/pa paid/ ution yabl payabl (Rs) (Rs) Month.. No. of Total Employ days for amoun s' which t of shar of wags wags contrib paid/pa paid/ ution yabl payabl (Rs) (Rs) Summary.. Total No. of days for which wags paid/pa yabl in Contrib ution priod Total amount of wags paid/ payabl in Contrib ution priod (Rs) Total Employ s' shar of Contrib ution in Contrib ution priod (Rs) 19 20 21 22 23 24 25 26 27 28 Dai ly Wa g (25-26) (Rs.)
Total Employ rs' shar Grand Total Total Employ rs' shar Grand Total Paid on Paid on Not. Th figurs in Columns 7 to 24 shall b in rspct of wag priods nding in a particular calndar month.
43-47REG. FORM-7 (Confidntial) (Dposit this crtificat within 3 days with th appropriat Branch Offic to avoid possibl loss of bnfit undr Rgulation 64) Book No.. First/Intrmdiat/Final Crtificat Employs' Stat Insuranc Corporation (Rgulations 57, 58, 59).. Srial No. Stamp of Dispnsary Signatur or Thumb imprssion of th I.P. Dat of First Crtificat of spll of Sicknss or Disablmnt. Employr's Cod No. Branch Offic. Nam..s/w/d.Ins. No.. Crtifid that I hav xamind you today and that in my opinion: Any othr rmarks by th Mdical Officr.. (i)* (ii)* You now nd mdical tratmnt, attndanc and abstntion from work on mdical grounds by rason of (diagnosis) You hav continud to nd mdical tratmnt, attndanc and abstntion from work on mdical grounds up to and including this day by rason of (diagnosis).... (iii)* In my opinion you will b fit to rsum work tomorrow/on Attstd by Mdical Officr Not. Th dat of fitnss must in no cas b latr than th third day aftr th dat of th xamination in cas of First and Final Crtificat Dat.. Signatur Insuranc Mdical Officr Nam in Block Lttrs. * Strik out whichvr is not applicabl Important: Rubbr stamp 1. Any prson who maks fals statmnt or rprsntation for th purpos of obtaining bnfit whthr for himslf/som othr prson shall b punishabl with imprisonmnt up to 6 months or fin up to Rs 2000 or both. 2. This form should b compltd and submittd without dlay to th appropriat Branch Offic to scap pnal dduction of bnfit undr Rgulation 64 rad with Rgulation 99 of ESI (Gnral) Rgulations, 1950. 3. Insurd prson must sign, with dat, th claim form to avoid dlay and inconvninc.
48-49REG. FORM-8 (Confidntial) (Dposit this crtificat within 3 days with th appropriat Branch Offic to avoid possibl loss of bnfit undr Rgulation 64) Book No.. Spcial Intrmdiat Crtificat Employs' Stat Insuranc Corporation (Rgulations 61 and 89-B).. Srial No. Stamp of Dispnsary Signatur or Thumb imprssion of th I.P. Dat of First Crtificat of spll of Sicknss or Disablmnt. Employr's Cod No. Branch Offic. To..s/w/d.Ins. No.. Any othr rmarks by th Mdical Officr...... Attstation by Mdical Officr Crtifid that I hav xamind you.. today and that in my opinion you hav continud to nd mdical tratmnt and hav rmaind incapabl to work up to and including this day by rason of.i furthr crtify that by judging your prsnt condition it is found that your sicknss is of such a charactr that it will b unncssary to s you for th purpos of tratmnt mor frquntly than onc in wks, and you will rquir mdical tratmnt and will rmain incapabl to work at last up to th nd of.wks from this dat I propos to issu crtificats in this form at th intrval statd abov, so long as your condition dos not rquir mor frqunt attndanc. In my opinion you should now/nd not b rfrrd to a Mdical Board to dtrmin if you ar prmanntly disabld Dat.. Signatur Insuranc Mdical Officr with rubbr stamp Nam in block lttrs 56REG. FORM-9 Claim for Sicknss/T.D.B./Matrnity Bnfit for Sicknss Employs' Stat Insuranc Corporation (Rgulations 63 and 89-B) I.Insuranc No..s/w/d of. hrby claim Cash Bnfit for priod ovrlaf and stat (i)* That bcaus of sicknss/tmporary disablmnt/sicknss du to prgnancy/confinmnt/prmatur birth of child/miscarriag, I hav not bn at work sinc (ii)* I no longr claim to b sicknss/tmporary disabld/sick du to prgnancy/confinmnt/prmatur birth of child/miscarriag from. and I shall/did not tak up any work for rmunration bfor that dat. (iii)* I hav not bn in rcipt of any wags for th days of lav/holiday(s).
(iv)* I was not on strik during th priod of crtifid abstntion on account of sicknss/tmporary disablmnt i.. from to..for which th bnfit is claimd. I dsir paymnt in *cash at Branch Offic/By Mony Ordr. Nots: Signatur or T.I of Claimant Nam in Block Lttrs Addrss... 1. Any prson who maks fals statmnt or rprsntation for th purpos of obtaining bnfit whthr for himslf/som othr prson shall b punishabl with imprisonmnt up to 6 months or fin up to Rs 2000 or both. 2. This form should b compltd and submittd without dlay to th appropriat Branch Offic. 3. A final crtificat must b obtaind bfor rsuming work. * Strik out if not applicabl. 76-77REG. FORM-10 (Confidntial) Abstntion Vrification in rspct of Sicknss Bnfit/ Tmporary Disablmnt Bnfit/Matrnity Bnfit From: Th Managr...Branch Offic E.S.I. Corporation, To: M/s...... Employs' Stat Insuranc Corporation (Rgulation 52-A) Subjct: Vrification of abstntion from work in rspct of Shri/Smt/Km... Dar Sir(s) Ins. No...Dpartmnt... Th abov namd mploy of your factory has submittd a crtificat of incapacity for th priod from... to... and has dclard that h/sh has not workd on any day during th abov priod. H/Sh has furthr dclard that h/sh has not rcivd wags as dfind undr sction 2(22) of ESI Act, 1948 for any lav/holiday/wkly off/lay off and strik in rspct of any day during th abov priod and that h/sh was not on strik on any day during th abov priod. I shall b gratful if you confirm th xact position, in this rgard, on th form, appndd within 10 days of th rcipt of this form.
CONFIDENTIAL Yours faithfully, Managr...Branch Offic REPLY TO BE FURNISHED BY THE EMPLOYER IN RESPECT OF FORM NO. 10 Nam of th Insurd Prson/Insurd Woman... Insuranc No.... Rturnd with th rmarks that th mploy in qustion has not workd on any day during th priod from... to... or* that h/sh has workd on... during th priod from... to... It is furthr confirmd that (a) H/Sh rmaind on lav with wags for th priod from... to... (b) H/Sh rmaind on holidays with wags from... to... (c) H/Sh was on wkly off with wags for... (d) H/Sh was on lay-off with wags from... to... () H/Sh was on strik from... to... 2. In cas, th IP/IW is paid any wags for any of th days falling during th abovmntiond priod subsquntly, th sam will b notifid to you in du cours. 3. Th day procding th first day of absnc was*/was not a holiday for th Insurd Prson/Insurd Woman. Dat:... Signatur... * Strik out if not applicabl Nam in block lttr and dsignation... Cod No....
57REG. FORM-11 Accidnt Book EMPLOYEES' STATE INSURANCE CORPORATION (Rgulation 66) S I. N o. D a l o f N o t i c T i m o f N o t i c N a m a n d A d d r s s o f I n j u r d P r s o n S x A g I n s u r a n c N o. S h i f t, d p a r t m n t a n d O c c u p a t i o n o f t h m p l o y D t a il s o f I n j u r y C a u s N a t u r D a t T i m P l a c
1234567891 0 1 1 1 2 1 3 W h a t x a c t l y w a s t h i n j u r d p r s o n d o i n g a t t h t i N a m, o c c u p a t i o n, a d d r s s a n d s i g n a t u r o r t h t h u m S i g n a t u r a n d d s i g n a t i o n o f t h p r s o n w h o m a k s t N a m, a d d r s s a n d o c c u p a t i o n o f t w o w i t n s s s R m a r k s, i f a n y
m o f a c c i d n t b i m p r s s i o n o f t h p r s o n ( s ) g i v i n g n o t i c h n t r y i n t h A c c i d n t B o o k 1 4 1 5 1 6 1 7 1 8
1. Nam and Addrss of Factory/Establishmnt and Tlphon No. 2. Natur of Industry or businss 58-61REG. FORM-12 Accidnt Rport from Employr Employs' Stat Insuranc Corporation (Rgulation 68) 3. Employr's Cod No. 4. Branch Offic 5. Nam and addrss of injurd prson 6. Sx and Ag 7. Occupation 8. Insuranc No. 9. Dpartmnt 10. Shift/Hrs. of work on th dat of accidnt 11. Hour at which h startd work on th day of accidnt 12. Dat and hour of accidnt 13. Exact plac of accidnt 14. Natur and xtnt of injury (.g. fatal, loss of fingr, fractur of lg, scald tc.) 16. Addrss of prmiss whr accidnt happnd 15. Location of injury (right lg, lft hand or lft y tc.) 17. Dat of dath in cas th injurd prson dis 18. In cas th accidnt happnd whil mting an mrgncy, plas stat: (i) Its natur 19. Dispnsary/IMP allottd to injurd prson 21. Nam and Addrss of witnss: 1. 2. (ii) Whthr th injurd prson, at th tim of th accidnt was mployd for th purpos of his mployr's trad or businss in or about th prmiss at which th accidnt took plac 20. Dr or Dispnsary or Hospital from whr injurd prson rcivd or is rciving tratmnt 22. Whthr wags in full or part ar payabl to him for th day of accidnt 23. Whthr th injurd prson was an mploy undr sction 2(9) of th Act on th day of accidnt 24. Whthr contribution was payabl by him for th day on which accidnt occurrd 25. Caus of accidnt (a) Stat xactly what th injurd prson was doing at th tim of accidnt i.. brif dscription of how th accidnt occurrd. (b) Was th injurd prson, at th tim of accidnt, acting in contravntion of Ys Ys No No
(1) th provision of any law applicabl to him or. or (2) any ordrs givn by or on bhalf of his mployr or or (3) acting without instructions from his mployr.. (c) In cas rply to b(1), (2) or (3) is Ys, stat whthr th act was don for th purpos of and in connction with th mployr's trad or businss 26. In cas th accidnt happnd whil travlling in th mployr's transport, stat whthr th injurd prson was travlling: (1) as a passngr to or from his plac of work (2) with th xprss or implid prmission of his mployr (3) th transport is bing opratd by or on bhalf of th mployr or som othr prson by whom it is providd in pursuanc of arrangmnt mad with th mployr, and (4) th vhicl was bing/not bing opratd in th ordinary cours of public transport srvic I crtify that to th bst of my knowldg and blif, th abov particulars ar corrct in vry rspct Dat of dispatch of rport (For Official Us) Signatur of th Employr. Nam in block lttrs. Dsignation (with Stamp) Diary No. of accidnt rgistr and dat Signatur of B.M. Not. Accidnt Rport is rquird to b submittd to th appropriat Branch Offic as wll as to Insuranc Mdical Officr/I.M.P. within 24 hours of th rcipt of notic of injury. In cas of fatal or srious accidnts, it must b submittd immdiatly to avoid lgal pnal action undr sction 85.
(In Duplicat)* 62REG. FORM-13 Dath Crtificat (For Dpndant's Bnfit or Funral Expnss) Employs' Stat Insuranc Corporation (Rgulations 79 and 95-C) Book No. Stamp of Dispnsary Nam of th dcasd Insurd Prson...s/w/d of.. No. S1. No Insuranc I crtify that in my opinion th abov namd dcasd Insurd Prson did on th day of as a rsult of an injury/du to* I **had bn attnding him/hr for providing mdical bnfit bfor his/hr dath and I attndd him/hr for th last tim on th day of Any othr rmarks by th Mdical Officr Datd: *Plas indicat th nam of th disas Signatur Insuranc Mdical Officr/I.M.P. Nam in block lttrs and rubbr stamp ** May b suitably amndd if th Insuranc Mdical Officr/I.M.P. has not attndd th dcasd prson bfor his/hr dath
72REG. FORM-14 Claim for Prmannt Disablmnt Bnfit Employs' Stat Insuranc Corporation (Rgulation 76-A) I..s/w/d.. Insuranc No.. having bn dclard as prmanntly disabld by th Mdical Board/Mdical Appal Tribunal /Employs' Insuranc Court, claim Prmannt Disablmnt Bnfit accordingly for th priod from.. to.. Th amount du may b paid to m by mony ordr/in cash at Branch Offic Datd.... Signatur or thumb imprssion of th Claimant Nam in block lttrs.. and Addrss..... Important: Any prson who maks a fals statmnt or rprsntation for th purpos of obtaining bnfit, whthr for himslf or for som othr prson, commits an offnc punishabl with imprisonmnt for a trm which may xtnd up to six months or with a fin up to Rs 2000, or with both
63REG. FORM-15 Claim Form for Dpndant's Bnfit Employs' Stat Insuranc Corporation (Rgulation 80) Nam of th dcasd Insurd Prson..Ins. No S/W/D of.dat of Dath.Last mployd as.. by. I/W th following, bing dpndants of th abov namd dcasd Insurd Prson, hrby claim and accordingly apply for dpndant's bnfit on account of his/hr dath: Nam of th dpndant Sx Ag or yar of birth Marital status Rlationship with th dcasd Prsnt Addrss Nam of guardian in cas of minor 1 2 3 4 5 6 7 I/W dclar that th particulars givn abov ar tru to th bst of my/our knowldg and blif I/W also dclar that to th bst of my/our knowldg and blif, thr is no othr dpndant ntitld to claim Dpndant's Bnfit in r/o th dath of th abov notd dcasd I.P., sav and xcpt thos mntiond abov Signatur* 1.. 2.. 3.. 4.. ATTESTATION** Crtifid that th dclarations, as mad abov, ar tru to th bst of my knowldg and blif Nam in block lttrs and Rubbr Stamp or Sal of th Attsting Authority Signatur. Dsignation. * All major dpndants should sign individually and th guardian to sign in cas of a minor dpndant ** This crtificat is to b givn by (i) an officr of th Rvnu, Judicial or Magistrial Dpartmnts of Govrnmnt, or (ii) a Municipal Commissionr, or (iii) a Workmn's Compnsation Commissionr, or (iv) th Had of th Gram Panchayat undr th official sal of th Panchayat, or (v) M.L.A./M.P., (vi) Gazttd Officr, or (vii) a mmbr of Local Committ/Rgional Board of th ESI Corporation, or (viii) any othr authority considrd appropriat by th Branch Managr. Important: Any prson who maks a fals statmnt or rprsntation for th purpos of obtaining bnfit, whthr for himslf or for som othr prson, commits an offnc punishabl with imprisonmnt for a trm which may xtnd up to six months or with a fin up to Rs 2000, or with both
64REG. FORM-16 Claim for Priodical Paymnts of Dpndants' Bnfit Employs' Stat Insuranc Corporation (Rgulation 83-A) Nam of th dcasd Insurd Prson.Ins. No.I. bing th of th abov namd dcasd Insurd Prson and also bing his/hr dpndant, do hrby claim Dpndants' Bnfit for th priod from.. to.. Th amount du may b paid to m I also dclar that *(i) I hav not marrid*/r-marrid, so far by mony ordr In cash/by chqu at Branch Offic (Applicabl only in cas of a fmal dpndant) *(ii) I hav not attaind th ag of 18 yars (Applicabl in cas of minor mal/fmal dpndant) *(iii) I am still infirm (Applicabl only in cas of a lgitimat/adoptd* infirm son or a lgitimat/adoptd* unmarrid infirm daughtr who has attaind 18 yars of ag. Th claim to b accompanid, if rquird, by a crtificat of spcifid authority) Dat. Nam in block lttrs of Claimant/Guardian * Plas strik out whichvr is not applicabl ** Applicabl in th cas of a claim by a major dpndant *** Applicabl in th cas of a claim for a minor dpndant **Signatur or Thumb imprssion of th Claimant Prsnt Addrss. or ***Signatur/Thumb imprssion of th Guardian for.. (Nam of th minor Dpndant) through.(nam of th Guardian).. his/hr. (Rlationship with th Minor) [Plas rfr to Rul 58 of th ESI (Cntral) Ruls, 1950]
Employr's Cod No Insurd Woman's Nam Insuranc No Wif/Daughtr of 65 REG. FORM-17 Crtificat/Notic of Prgnancy Matrnity Bnfit EMPLOYEES' STATE INSURANCE CORPORATION (Rgulation 87) Signatur or thumb imprssion of th Insurd Woman Book No.. Srial No.. Stamp of th Dispnsary Crtifid that I hav xamind th abov mntiond Insurd Woman today and that in my opinion sh prgnant and hr prgnancy appars to b wks old Signatur of midwif, if any Datd: Signatur or countrsignatur of th Insuranc Mdical Officr Nam in block lttrs and Rubbr Stamp Any othr rmarks... I, Insuranc No.... Wif/daughtr of.. hrby giv notic of prgnancy Prsnt addrss:.. Prsnt/last mployr Dat:. Signatur or thumb imprssion of th Insurd Woman 66-67 REG. FORM-18 Crtificat of Expctd Confinmnt/Confinmnt/ Miscarriag Matrnity Bnfit EMPLOYEES' STATE INSURANCE CORPORATION (Rgulations 88 and 89) Signatur or thumb imprssion of th Insurd Woman Employr's Cod No. Book No.. Srial No. Insurd Woman's Nam... Insuranc No. Wif/Daughtr of. Stamp of th Dispnsary I*. Crtifid that I hav xamind th abovmntiond Insurd Woman today and that in my opinion sh may xpct to b confind on or about.. II*. Crtifid that I attndd th abovmntiond Insurd Woman in connction with hr confinmnt/ miscarriag at.. (addrss) and that sh was
thr dlivrd of a child on th. day of.. Dat:. Any rmarks. * Dlt whichvr is not applicabl Signatur of midwif, if any Signatur or countrsignatur of th Insuranc Mdical Officr Nam in block lttrs and Rubbr Stamp
68-70REG. FORM-19 Claim for Matrnity Bnfit and Notic of Work EMPLOYEES' STATE INSURANCE CORPORATION (Rgulations 88, 89 and 91) Employr's Cod No. Insurd Woman's Nam... Insuranc No. Wif/Daughtr of... Signatur or thumb imprssion of th Insurd Woman Book No. Srial No.. Stamp of th Dispnsary I, th abovmntiond Insurd Woman hrby claim Matrnity Bnfit for xpctd confinmnt/ confinmnt*/miscarriag with ffct from.. I furthr dclar that I hav casd*/shall cas to work for rmunration with ffct from th aforsaid dat *I do hrby giv notic that I hav takn up/shall tak up work for rmunration with ffct from I hav drawn matrnity bnfit only up to. Prsnt Employr**. Dpartmnt, shift and occupation Prsnt addrss Signatur/Thumb imprssion of th Insurd Woman Nam of th Branch Offic Dat: * Plas dlt whichvr is not applicabl ** If not in mploymnt, mntion th particulars of last mployr Important: 1. No work for rmunration shall b takn up during th priod for which Matrnity Bnfit is bing claimd or is to b claimd 2. Notic for rsumption of work must b snt bfor any work is takn up 3. Any prson who maks a fals statmnt or rprsntation for th purpos of obtaining bnfit, whthr for hrslf or for som othr prson, commits an offnc punishabl with imprisonmnt for a trm which may xtnd up to six months, or with a fin up to Rs 2000, or with both
71REG. FORM-20 Claim for Matrnity Bnfit aftr th dath of an Insurd Woman laving bhind th Child Employs' Stat Insuranc Corporation (Rgulation 89-A) Claim arising from th dath on.... of Ms wif/daughtr of..., having Insuranc No and last mployd by M/s. I.. *bing rlatd to th abov namd dcasd Insurd Prson as hr. and bing hr nomin/bing hr lgal rprsntativ (applicabl if th I.W. dis laving no nomin), hrby claim Matrnity Bnfit for th priod from. to.. I also dclar that **(i) th dcasd Insurd Woman did on.. laving bhind th child who is still aliv; or **(ii) th dcasd Insurd Woman did on laving bhind th child who also did on. Th amount du may b paid to m by Mony Ordr/in cash at Branch Offic I furthr dclar that th particulars, as givn hrinabov, ar tru to th bst of my knowldg and blif Dat.. ATTESTATION. Signatur/Thumb imprssion of th Claimant Nam in block lttrs and.. Addrss of claimant... ***Crtifid that th dclarations, as mad hrinabov, ar tru to th bst of my knowldg and blif * Strik out this lin if not applicabl Nam in block lttrs and Rubbr Stamp or Sal of th Attsting Authority ** Dlt ithr (i) or (ii), as may not b applicabl in th cas Signatur with dat Dsignation.... *** This crtificat is to b givn by (i) an officr of th Rvnu, Judicial or Magistrial Dpartmnt; or (ii) a Municipal Commissionr, or (iii) a Workmn's Compnsation Commissionr; or (iv) th Had of Gram Panchayat undr th official sal of th Panchayat, or M.L.A./M.P.; or (v) a Gazttd Officr of th Cntral/Stat Govrnmnt/Mmbr of th Local Committ/Rgional Board; or (vi) any othr authority considrd as appropriat by th Branch Managr concrnd Important: 1. This claim form, duly filld up, is rquird to b submittd to th appropriat Branch Offic, togthr with a dath crtificat in Form 24-B, within 30 days of th dath of th Insurd Woman 2. Any prson who maks a fals statmnt or rprsntation for th purpos of obtaining bnfit, whthr for himslf or for som othr prson, commits an offnc punishabl with imprisonmnt for a trm which may xtnd up to six months or with a fin up to Rs 2000 or with both
71aREG. FORM-21 Dath Crtificat in cas of Confinmnt for Claiming Matrnity Bnfit Employs' Stat Insuranc Corporation (Undr Rgulation 89-A) Book No. Srial No.... I crtify that in my opinion Stamp of th Dispnsary Nam of th dcasd Insurd woman. W/D of Insuranc No. (i) th abov namd dcasd Insurd Woman did on as a rsult of... during hr confinmnt/*during a priod of... wks immdiatly following hr confinmnt, laving bhind th child (Caus of dath) *(ii) th said child also did on... as a rsult of... Also crtifid that I had bn attnding hr*/and also hr said child for providing mdical bnfit bfor *hr dath/hr said child's dath and I attndd hr for th last tim on and hr said child for th last tim on Any othr rmarks.. Dat.. Signatur of Insuranc Mdical Officr/Insuranc Mdical Practitionr Rubbr Stamp and nam in block lttrs Not: (1)* Plas dlt whichvr is not applicabl (2) Th languag may b suitably amndd if th Insuranc Mdical Officr/Insuranc Mdical Practitionr had not attndd th dcasd prson bfor hr/hr child's dath
73REG. FORM-22 Funral Expnss Claim Form Employs' Stat Insuranc Corporation (Rgulation 95-E) Claim arising out of dath on.. of. s/w/d of. agd. yars, having Insuranc No... and last mployd as... by M/s.. Cod No.. I.. s/w/d of.. agd... yars dclar: *(i) that I am th ldst surviving mmbr of th family of th dcasd Insurd Prson, whos particulars ar furnishd hrinabov, and that I actually incurrd an xpnditur of Rs.. (Rups only) ncssary for th funral of th said dcasd prson or *(ii) that th dcasd Insurd Prson, whos particulars ar furnishd thrinabov, did not hav a family/was not living with his/hr family at th tim of his/hr dath and that I actually incurrd an xpnditur of Rs (Rups.. only) on th funral of th dcasd Insurd Prson Accordingly, I do hrby claim funral xpnss for th amount of Rs.. (Rups. only) Dat.. Nam in block lttrs ATTESTATION Signatur/Thumb imprssion of th Claimant **Crtifid that th dclarations, as mad hrinabov, ar tru to th bst of my knowldg and blif Nam in block lttrs and Rubbr Stamp or Sal of th Attsting Authority * Dlt ithr (i) or (ii), which may not b applicabl in th cas Signatur with dat Dsignation.... Dat ** This crtificat is to b givn by (i) an officr of th Rvnu, Judicial or Magistrial Dpartmnt; or (ii) a Municipal Commissionr; or (iii) a Workmn's Compnsation Commissionr; or (iv) th Had of Gram Panchayat undr th official sal of th Panchayat, or M.L.A/M.P.; or (v) a Gazttd Officr of th Cntral/Stat Govrnmnt, Local Committ/Rgional Board; or (vi) any othr authority considrd as appropriat by th Branch Managr concrnd Important: Any prson who maks a fals statmnt or rprsntation for th purpos of obtaining
bnfit, whthr for himslf or for som othr prson, commits an offnc punishabl with imprisonmnt for a trm which may xtnd up to six months or with a fin up to Rs 2000 or with both Not: In th cas of a minor, th guardian should sign th claim form on bhalf of th minor and thn add th following blow his/hr signatur: through his/hr (Nam of th Minor) (Nam of th Guardian) (Rlationship with th Minor)
74REG. FORM-23 (To b submittd along with claim of Jun and Dcmbr) Lif Crtificat for Prmannt Disablmnt Bnfit EMPLOYEES' STATE INSURANCE CORPORATION (Rgulation 107) Insuranc No. of Prmanntly disabld prson *Crtifid that Shri/Smt w/s/d of is aliv this. day of. 20... Signatur.. Nam in block lttrs of signing Claimant. Dsignation with Rubbr Stamp/Sal of th Attsting Authority Dat. Important: Any prson who maks a fals statmnt or rprsntation for th purpos of obtaining bnfit whthr for himslf or for som othr prson, commits an offnc punishabl with imprisonmnt for a trm which may xtnd up to six months or with a fin up to Rs 2000 or with both * This crtificat is to b givn by (i) an officr of th Rvnu, Judicial or Magistrial Dpartmnt; or (ii) a Municipal Commissionr; or (iii) a Workmn's Compnsation Commissionr; or (iv) th Had of Gram Panchayat undr th official sal of th Panchayat; or (v) M.L.A./M.P.; or (vi) a Gazttd Officr of th Cntral/Stat Govrnmnt; or (vi) a mmbr of th Rgional Board/Local Committ of th ESIC; or (viii) any othr authority considrd as appropriat by th Branch Managr concrnd
75REG. FORM-24 (To b submittd along with claim of Jun and Dcmbr) Dclaration and Crtificat for Dpndant's Bnfit EMPLOYEES' STATE INSURANCE CORPORATION (Rgulation 107-A) Nam of th dcasd Insurd Prson.. Ins. No. I, bing th..of th abov namd dcasd Insurd Prson and also bing his dpndant, do hrby solmnly dclar: *(i) that I hav not marrid/rmarrid so far (To b givn only by a fmal dpndant) *(ii) that I hav not yt attaind th ag of ightn yars (To b givn only in rspct of a minor mal or fmal dpndant) *(iii) that I hav attaind th ag of ightn yars but continu to b infirm (To b givn by a lgitimat/adoptd infirm son or by a lgitimat/adoptd infirm daughtr. Crtificat as spcifid, to b attachd, if rquird) Prsnt Addrss:.. Dat Nam in block lttrs of signing claimant CERTIFICATE Signatur or thumb imprssion of th dpndant or Signatur or thumb imprssion of th Guardian in cas of a minor dpndant Nam of th minor.. Through. (Nam of th Guardian) his/hr (Rlationship with th Minor) **Crtifid that Shri/Smt/Kumari.. w/s/d of.. is aliv this day, th.. day of 20. and that th dclarations mad abov ar tru to th bst of my knowldg and blif Dat Nam in block lttrs and Rubbr Stamp or Sal of th Attsting Authority * Strik out whichvr is not applicabl Signatur. Dsignation. ** This crtificat is to b givn by (i) an officr of th Rvnu, Judicial or Magistrial Dpartmnt; or (ii) a Municipal Commissionr; or (iii) a Workmn's Compnsation Commissionr; or (iv) th Had of Gram Panchayat undr th official sal of th Panchayat; or (v) M.L.A./M.P.; or (vi) a Gazttd Officr of th Cntral/Stat Govrnmnt; or (vii) a mmbr of th Rgional
Board/Local Committ of th ESIC; or (viii) any othr authority considrd appropriat by th Branch Managr concrnd Important: Any prson who maks a fals statmnt or misrprsntation for th purpos of obtaining bnfit, whthr for himslf or som othr prson, commits an offnc punishabl with imprisonmnt for a trm which may xtnd up to six months or with a fin up to Rs 2000 or with both
SCHEDULE I 78[***] SCHEDULE II 78[***] 79[SCHEDULE III [Rgulation 76B] COMMUTATION VALUES FOR PERMANENT DISABLEMENT BENEFIT Ag last birthday of insurd prson on th dat on which th application for commutation is rcivd in th appropriat offic Th factor with which th daily rat of bnfit is to b multiplid Ag last birthday of insurd prson on th dat on which th application for commutation is rcivd in th appropriat offic Th factor with which th daily rat of bnfit is to b multiplid 1 2 1 2 17 yars and blow 5690 42 yars 4860 18 yars 5670 43 yars 4800 19 yars 5660 44 yars 4740 20 yars 5640 45 yars 4670 21 yars 5620 46 yars 4610 22 yars 5600 47 yars 4540 23 yars 5580 48 yars 4470 24 yars 5560 49 yars 4400 25 yars 5540 50 yars 4330 26 yars 5510 51 yars 4250 27 yars 5480 52 yars 4180 28 yars 5460 53 yars 4100 29 yars 5420 54 yars 4020 30 yars 5390 55 yars 3930 31 yars 5360 56 yars 3850 32 yars 5320 57 yars 3760 33 yars 5280 58 yars 3670 34 yars 5240 59 yars 3590 35 yars 5200 60 yars 3500 36 yars 5160 61 yars 3400 37 yars 5110 62 yars 3310 38 yars 5070 63 yars 3220 39 yars 5020 64 yars 3130 40 yars 4970 65 yars 3030 41 yars 4910 66 yars 2940 67 yars 2850 74 yars 2200 68 yars 2750 75 yars 2120 69 yars 2660 76 yars 2030
70 yars 2570 77 yars 1950 71 yars 2470 78 yars 1860 72 yars 2380 79 yars 1780 73 yars 2290 80 yars 1700 NOTIFICATION UNDER REGULATION 27 OF EMPLOYEES STATE INSURANCE (GENERAL) REGULATIONS, 1950 It is notifid for gnral information that th Dirctor-Gnral undr powrs vstd in him by virtu of th provisions of rgulation 27 of th Employs Stat Insuranc (Gnral) Rgulations, 1950, has spcifid th form of Crtificat of contributions payabl as pr Annxur I of this notification. 2. Th mployrs who mak paymnt of contribution in tim will continu to submit th rturn of contribution undr rgulation 26 of th Employs Stat Insuranc (Gnral) Rgulations, 1950, as usual. Howvr, from th contribution priod nding Sptmbr 1995, onwards, thos mployrs who ar unabl to submit th aforsaid rturn of contribution du to non-paymnt of contribution (mployrs as wll as mploys shar) to th Corporation will b rquird to submit th crtificat of contributions payabl now spcifid, within th sam tim-limit prscribd undr rgulation 26 of th Employs Stat Insuranc (Gnral) Rgulations, 1950. 3. Th appropriat offic of th Corporation will start accpting th crtificat of contributions payabl to b submittd by th dfaulting mployrs within th tim prscribd undr rgulation 26 of th Employs Stat Insuranc (Gnral) Rgulations, 1950, from th contribution priod nding Sptmbr 1995, onwards. 4. Th appropriat offic for th purpos of submission of th said crtificat of contributions payabl will b th concrnd rgional offic as alrady notifid for th purpos of submission of rturn of contribution undr rgulation 26 of th Employs Stat Insuranc (Gnral) Rgulations, 1950. 5. In th first instanc, th provisions of this notification will com into forc in th Stats of Uttar Pradsh, Haryana, Dlhi, Maharashtra, Punjab, Rajasthan, Karnataka and Wst Bngal with ffct from th contribution priod nding Sptmbr 1995, onwards. Nam and addrss of th factory or stablishmnt Particulars of th principal mployr (a)nam (b)dsignation (c)rsidntial addrss ANNEXURE-I CERTIFICATE OF CONTRIBUTIONS PAYABLE Employs Stat Insuranc Corporation Crtificat of contribution (Rgulation 27) Employr s Cod No........................ priod from...to... I furnish blow th dtails of th mployr s and mploy s shar of contribution in rspct of th undr mntiond insurd prsons. I hrby dclar that th dtails includ vry mploy mployd dirctly or through an immdiat mployr or in connction with th work of th factory/stablishmnt or any work connctd with th administration of th factory/stablishmnt or purchas of raw matrials, sal or distribution of finishd products, tc., to whom th contribution priod to which this crtificat rlats, applid and that th
contribution in rspct of mployr s and mploy s shar has bn corrctly calculatd and is payabl in accordanc with th provisions of th Act and Rgulations rlating to th paymnt of contributions. Total contribution payabl is amounting to Rs....comprising of Rs....as mployr s shar and Rs....as mploy s shar (Total of column 6 of th crtificat). 1. I dclar that th particulars givn abov ar corrct to th bst of my knowldg and blif. 2. I dclar that th factory/stablishmnt was covrd undr th Employs Stat Insuranc Act during th contribution priod to which th abov information prtains. Plac :...... Dat :... Important instructions : Signatur... Dsignation 1. If any I.P. is appointd for th first tim and/or lav srvic during th contribution priod, indicat A... or L... [dat in th rmarks column (No. 8)]. 2. Plas indicat insuranc numbrs in chronological (ascnding) ordr. 3. Figurs in columns 4, 5 and 6 shall b in rspct of wag priods ndd during th contribution priod. 4. Invariably strik total of columns 4, 5 and 6. 5. No ovr-writings shall b mad. Any corrctions should b signd by th mployr. 6. Evry pag should bar full signatur and rubbr stamp of th mployr. 7. Daily wags in column 7 shall b calculatd by dividing figurs in column 5 by figurs in column 4 to two dcimal placs. Not. Submission of this crtificat of contributions payabl dos not absolv th mployr of th rsponsibility to submit th rturn of contribution undr rgulation 26 or any othr rturns nshrind in various provisions of th Employs Stat Insuranc Act and th Employs Stat Insuranc (Gnral) Rgulations, 1950. Sl. No. Ins. No. Nam of insurd prson No. of days for which wags paid Total amount of wags paid Employs contribution dductd Daily wags Rmarks (1) (2) (3) (4) (5) (6) (7) (8) Plac :...... Dat :... Signatur... Dsignation Rubbr Stamp of mployr Sourc : Notification No. V-33/15-1-95-INS.IV, datd 21-8-1995. ***