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Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself or for some other person renders himself liable to prosecution. 

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Claim forms 

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Form-01

 

Employers Registration Form 
To be submitted to Sub Regional Office promptly or within maximum 15 days of applicability of ESI Act for registration and getting ESI Code No.(s). 
 
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Form-1
Declaration Form (DF) in respect of coverable employees 
To be submitted to Appropriate Branch Office within 10 days from the date of  insurable employment along with return of Declaration Form 
 
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Form-1B
Subsequent change(s) in the family particulars to be furnished to the Branch Office concerned. Download now 
Form-3
Return of Declaration Form Download now 

 

Form-6
Return of Contributions (RC) based on Form-7 Register with insurance number in the ascending order to be submitted in quadruplicate for half-yearly periods 
i.e. April to September & October to March to Appropriate Branch Office within 42 days from expiry of periods i.e. by 11th November/ 12th May.
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Form-6A
Return relating to advance payment of contribution in the same manner as in case of Form-6. Download now 
Form-7
[download]
Register of employees under Regulation-32.  The wage particulars of all the coverable employees along with insurance numbers have to be recorded contribution period wise.  The Register is to be collected by the employer from market.  

Form-12  
[download]

 

Form for claiming cash benefits relating to SB/ESB/TDB/MB etc. from Branch Offices. Download now 
Form-13   Download now 
Form-14   Download now 
Form-16 Accident Report in case of employment injury to be prepared in triplicate. The original copy is to be furnished to the concerned Branch Office within 48 hours in ordinary case and immediately in respect of death cases. One copy is to be sent to Chief Inspector of Factories and another to the Insurance Medical Officer concerned. Download now 
Form-18A Form for claiming periodical Dependantís Benefit. Download now 
Forms-18A &27 Declaration Certificate for claiming Dependantís Benefit. Download now 
Form-24  Maternity Benefit - Notice of work Download now 
Form-24A Form to claim Maternity Benefit after death of an Insured Person leaving behind the child. Download now 
Form-24B Maternity Benefit Death Certificate Download now 
Form-25 Form for claiming PDB from Branch Office. Download now 
Form-25A Form for claiming Funeral Expenses under Regulation 95E to be submitted alongwith Death Certificate/ Declarations duly attested within 3 months from the date of death. Download now 
Form-26 Live certificate as required under Regulation 107 for claiming PDB at half-yearly interval i.e. January/July. Download now 
Form-28 Abstention verification certificate.  Employer has to confirm abstention position in respect of a particular insured person/woman as per request of Branch Office Manager for speedy settlement of claims.  
ESIC-32 Particulars of wage paid/payable to ascertain the benefit rates of TDB where the employment injury happened before completion of first Wage Period/Contribution Period.  
ESIC-37 Certificate of re-employment /continuing employment to be furnished in case of exit cases.  
ESIC-53

Application for changes in dispensary/residential address to be furnished to concerned Branch Office.

 
ESIC-71 In absence of RC/CCP, wage/contribution particulars to settle claims of employees to be furnished by employer on demand.  
ESIC-72-A Application for Duplicate Identity Card /Replacement of Defaced Identity Card duly authenticated by IMP/employer.  
ESIC-86 Certificate of employment to authorize medical benefit to newly appointed employees prior to receipt of IC or Temporary Identity Certificate. Download now 
ESIC-105 Certificate of employment to authorize medical treatment at temporary resident on leave/ tour etc. valid for 3 months.  
 
  Definitions
  Employee
  Dependant
  Employment injury
   
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