Employees' State Insurance (General) Regulations, 1950

CHAPTER I

Short title and extent .-(1) These regulations may be called the Employees' State Insurance (General) Regulations, 1950.

(2) They extend to the whole of India.

Definitions.- In these regulations, unless the context otherwise requires-

(a) "Act" means the Employees' State Insurance Act, 1948 (34 of 1948);

(b) "appointed day' means with reference to any area, factory or establishment, the day from which the whole of Chapters IV and V of the Act apply to such area, factory or establishment, as the case may be;

(c) "appropriate office", "appropriate [Branch office]" or "appropriate regional office", shall mean with reference to any action taken under these regulations, such office of the Corporation as may be specified for that purpose under a general or special order of the Corporation;

(d) "Central rules" means the rules made by the Central Government under section 95 of the Act;

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(f) [***]

(g) "employer" means the principal employer as defined in the Act;

(h) "employer's code number" means the registration number allotted by the appropriate regional office to a factory or establishment for the purposes of the Act, the rules and these regulations;

(i) "factory or establishment" means a factory or an establishment to which the Act applies;

(j) "form" means a form appended to these regulations;

[(k) "identity card" means a permanent identity card issued by the appropriate office to an insured person for identification for the purposes of the Act, the rules and these regulations;]

(kk) "family identity card" means a card issued by the appropriate office to an insured person for identification of his family for the purposes of the Act, the rules and these regulations;

(l) "Social Security Officer" means a person appointed as such by the Corporation under section 45 of the Act;

(m) "instructions" means instructions or orders issued by the Corporation or by such officer or officers of the Corporation as may be authorized by the Corporation in this behalf;

(n) 'insurance medical officer' means a medical practitioner appointed as such to provide medical benefit and to perform such other functions as may be assigned to him and shall be deemed to be a duly appointed medical practitioner for the purposes of Chapter V of the Act;

(o) "insurance number" means a number allotted by the appropriate office to an employee for the purposes of the Act, the rules and these regulations;

(p) ["Branch office"] and "regional office" shall mean, according to the context, such subordinate office of the Corporation, set up at such place and with such jurisdiction and functions as the Corporation may, from time to time determine;

(q) ["Branch Manager"] means a person appointed by the Corporation as such or the office-in-charge of a [Branch office];

(r) "state rules" means the rules made by a State Government under section 96 of the Act;

(s) "regional director" means a person appointed by the Corporation as such for a specified region;

(t) "registered midwife" means a person who is registered as a midwife under any law in force in any State providing for registration of nurses and midwives

(u) "rules" means rules made by the Central or a State Government under the Act;

(v) "specified" means specified by instructions issued from time to time by the Corporation or any authorized officer;

(w) "Year" means a calendar year except when specifically stated otherwise;

(x) All other words and expressions have the meanings respectively assigned to them in the Act or the rules, as the case may be.

The manner in which the Corporation may exercise its powers.-(1) Where a regulation empowers the Corporation to specify, prescribe, provide, decide or determine anything or to do any other act, such powers may be exercised by a resolution of the Corporation or subject to the provisions of section 18 of the Act by a resolution of the Standing Committee:

PROVIDED that the Corporation or the Standing Committee may delegate any of the powers under these regulations to a sub-committee or to such officers of the Corporation as it may specify in that behalf:

PROVIDED FURTHER that no power shall be delegated under this regulation which under the Act is required to be exercised by the Corporation only.

(2) Any appointment to be made by the Corporation under these regulations shall be made by the Director General or by such other officers as may be authorized in this behalf by the Standing Committee.

3-A. Exercise of powers by an office.-Where a power is to be exercised by the appropriate office or appropriate [Branch office] or appropriate regional office it shall be exercised by the officer for the time being in charge thereof or by such other officer as may be authorized for the purpose under general or special orders of the Director-General

[4. Contribution and benefit periods -Contribution periods and the corresponding benefit periods shall be as under:

Contribution Period	Corresponding benefit period
1^st April to 30^th September	1^st January of the year following to 30^th June
1^st October to 31^st March of the year following	1^st July to 31^st December:

PROVIDED that in the case of a person who becomes an employee within the meaning of the Act for the first time, the contribution period shall commence from the date of such employment in the contribution period current on that day and the corresponding benefit period for him shall commence on the expiry of the period of nine months from the date of such employment.]

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Meetings of the Corporation, the Standing Committee and the Medical Benefit Council -The meetings of the Corporation, the Standing Committee and the Medical Benefit Council shall be held in accordance with the Central Rules at such time and place as maybe fixed by Chairman. concerned.
Decision by majority -Every matter coming up for decision before a meeting of the Corporation, the Standing Committee or the Medical Benefit Council shall be decided by a majority of persons present and voting at the time of the meeting and in case of equality of votes the Chairman of the meeting shall have an additional casting vote.
Mode of exercising vote -The votes shall be taken by show of hands and the names of persons voting in favor and against any proposition shall be recorded only if any member present requests the Chairman to do so.
Matters to be brought before the Corporation -In addition to the matters which are, under any specific provision of the Act or the Central Rules, required to be placed before the Corporation, the following matters shall be referred to the Corporation for its decision:

(a) regulations under section 97 and amendments thereto before final publication;

(b) any measures proposed under section 19 of the Act;

(d) any dispute proposed to be referred to arbitration under sub-section (4) of section 58;

(e) any proposal to set up hospitals under section 59;

(f) any proposal to grant exemption under section 91;

(g) any proposal to enhance benefits under section 99;

(h) any other matter which the Corporation or its Chairman may direct the Standing Committee or the Director-General to place before the Corporation.

Regional Boards -(1) A Regional Board may be set up for each State or Union Territory by the Chairman of the Corporation and shall consist of the following members, namely:-

(a) a Chairman to be nominated by the Chairman of the Corporation in consultation with the State Government or the administration of the Union Territory;

(b) a Vice-Chairman to be nominated by the Chairman of the Corporation in consultation with the State Government or the Administration of the Union Territory.

(c) one representative of the State or the Union Territory to be nominated by the State Government or the Administration of the Union Territory;

(d) [(i) the Administrative Medical Officer or any other Officer directly in charge of the Employee's State Insurance Scheme in the State or the Union Territory, ex officio;

(ii) the [State Medical Officer] of the Corporation, ex officio;]

(e) one representative each of the employers and employees from the State or the Union Territory to be nominated by the Chairman of the Corporation in consultation with such organization of the employers and the employees as may be recommended for the purpose by the State Government or the Union Territory;

(f) members of the Corporation other than the Chairman and the Vice-Chairman and officials, if any, amongst those nominated by the Central Government under clause (c) of section 4 of the Act, residing in the State or the Union Territory, ex officio;

(g) members of the Medical Benefit Council nominated by the Central Government under clauses (e), (f) and (g) of section 10 of the Act residing in the State or the Union Territory, ex officio :

[PROVIDED that where the Chairman of the Corporation so considers it to be expedient he may nominate such additional representatives of employers, and employees, not exceeding three from each side, with a view to providing for the adequate representation of important organizations and included in the nominations of the State Governments, or the Union Territory and to maintain parity between the number of representatives of such employers and employees:

PROVIDED FURTHER that the Chairman of the Corporation shall nominate such additional representatives of employers and employees not exceeding three from each side where the number of representatives of employers and employees including the ex officio members, is less than three each,]

[(2) A Regional Board may, if it considers it desirable, co-opt the officer-in-charge of a sub-regional officer set up within its boundaries and/or a member of the medical profession in the region and the person(s) so co-opted shall continue to be member(s) during the pleasure of the regional board.]

(3) The regional director or officer-in-charge of the regional office shall be the member secretary of the Board.

(4) (i) Save as expressly provided in this regulation, the term of office of the members of the regional board referred to in clause (e) of and the proviso to sub-regulation (1), shall be [three years] commencing from the date on which their nomination is notified, provided that the members of the regional board, shall, notwithstanding the expiry of the said period, continue to hold office until the nomination of their successors is notified.

(ii) Save as expressly provided in this regulation, the members of the regional board referred to in clause (c) of sub-section (1) shall hold office during the pleasure of the State Government nominating them.

(iii) A member of the regional board referred to in [clause (f)] of sub-regulation (1) shall cease to hold office when he ceases to be a member of the Corporation or ceases to reside in that area.

(iv) Any member referred to in clause (i) of this sub-regulation nominated to fill a casual vacancy shall hold office for the remainder of the term of office of the member in whose place he is nominated.

(v) An outgoing member shall be eligible for renomination.

(5) A member of the regional board referred to in clause (e) of and the proviso to sub-regulation (1) above, may resign his office by notice in writing to the Chairman of the Corporation, through the Chairman, Regional Board, and his seat shall fall vacant on the acceptance of the resignation.

(6) (i) A member of the regional board referred to in clause (e) of and the proviso to sub-regulation (1) shall cease to be a member of the Board if he fails to attend three consecutive meetings thereof provided that his membership may be restored by the Chairman of the Corporation on his being satisfied as to the unavoidable nature of the circumstances which led to his non-attendance.

(ii) When any person nominated to represent an employer's or employee's organization on the Regional Board has ceased to represent such organization, the Chairman of the Corporation may, by notification in the Gazette of India, declare that such person shall cease to be a member thereof with effect from such date as may be specified therein.

(7) The members of the Regional Board shall receive such fees and allowances as may be prescribed by the Central Government for members of the Corporation.

(8) A member shall be disqualified for being nominated or for being a member of the Regional Board-.

(i) if he is declared to be of unsound mind by a competent court; or

(ii) if he is an undischarged insolvent; or

(iii) if before or after the commencement of the regulation she has been convicted of an offence involving moral turpitude.

(9) The Secretary shall, with the approval of the Chairman, fix the date, time and place of, and also draw up the agenda for, every meeting. Notice of not less than ten days from the date of positing shall ordinarily be given to every member for each meeting, provided that if it is necessary to convene an emergency meeting, a reasonable notice thereof shall be given to every member. No matter other than that included in the agenda shall be considered except with the permission of the Chairman.

(10) No business shall be transacted at any meeting unless there is a quorum of not less than one-third of the number of the members on the Board:

PROVIDED that if at any meeting, sufficient number of members are not present to form a quorum, the Chairman may adjourn the meeting to a date not later than seven days from the date of original meeting and it shall thereupon be lawful to dispose of the business at such adjourned meeting irrespective of the number of members present.

(11) All matters shall be decided by a majority of persons present and voting and in case of equality of votes, the Chairman shall have a casting vote or a second vote.

(12) The Chairman or in his absence the Vice-Chairman of the Regional Boards shall preside at the meetings. In the event of the absence of both the Chairman and the Vice-Chairman the members present may elect one from amongst themselves to preside.

(13) (i) The minutes of each meeting showing inter alia the names of the members present thereat shall be forwarded to all members of the Regional Board as soon after the meeting as possible and in any case not later than fifteen days from the date of the meeting.

(ii) The records of the minutes of each meeting shall be signed by the Chairman after confirmation with such modifications as may be considered necessary at the meeting, at which the minutes are confirmed.

[(14) A Regional Board shall perform the following functions in respect of the Region for which it is set up:

(a) Such administrative and/ or executive functions as may, from time to time, be entrusted or delegated to it by a resolution, by the Corporation or the Standing Committee.

(b) To make recommendations from time to time in regard to changes which may in its opinion be advisable in the Act, Rules and Regulations and forms and procedures to be followed in the running of the scheme.

(c) To decide within the broad framework of the general decisions and programme of priorities of the Corporation, the following mattes, provided that where the specific approval of the Corporation or the appropriate government is required, such approval shall be taken:

(i) Extension of the scheme to other categories of establishments in accordance with the order of priorities laid down by the Corporation;

(ii) extension of scheme to new areas and extension of medical care to families;

(iii) adoption of special measures to meet peculiar conditions in the area;

(iv) improvement in benefits;

(v) provision of indoor medical treatment;

(vi) measures and arrangements for the rehabilitation of insured persons in the area, who are permanently disabled ;

(vii) securing compliance by employers with the various provisions of the Employees' State Insurance Act, the Regulations and other rules and instructions;

(d) To review from time to time the working of the Scheme in the State both on the medical side as well as cash benefit side and to advise the Corporation and State Government on measures to improve the working of the Scheme both in regard to payment of cash benefits and administration of medical benefit and in particular to promote preventive health measures, safety and personal hygiene and to review and check lax certification and other abuses of the scheme.

(e) To look into general grievances, complaints and difficulties of insured persons, employers, etc. as it may consider necessary;

(f)To advise the Corporation on such matters as maybe referred to it for advice by the Standing Committee or the Director General.

The Regional Board may set up suitable sub-committees for carrying out any of its functions and may seek the assistance or advice of local committees where necessary.]

(15) (i) If in the opinion of the Corporation, the Regional Board persistently makes default in performing the duties imposed on it by or under this regulation or abuses its powers, the Corporation may by notification in the Gazette of India supersede the Regional Board.

(ii) Upon the publication of a notification under clause (i) above superseding the Regional Board, all the members of the Regional Board shall from the date of such publication be deemed to have vacated their offices.

(iii) When the Regional Board has been superseded the Corporation may-

(a) immediately constitute a new Regional Board in accordance with this regulation; or

(b) appoint such agency for such period as it may think fit to exercise the powers and perform the functions of the Regional Board and such agency shall be competent to exercise all powers and perform all the functions of the Regional Board.

10A. Local committees.-(1) A local committee may be set up for such areas as may be considered appropriate by the Regional Board and shall consist of the following members, namely-

(a) a Chairman to be nominated by the Chairman, Regional Board,

(b) an official of the State to be nominated by the State Government;

(c) the Administrative Medical Officer-in-charge of the scheme in the area concerned, ex officio, or any other medical officer nominated by him;

(d) such number, not being less than two and not or more than four of representative of employers in the area as may be considered appropriate by the Chairman, Regional Board, to be nominated by him, in consultation with such employers' organizations as may be recommended for the purpose by the State Government;

(e) an equal number of representatives of employees in the area to be nominated by the Chairman, Regional Board, in consultation with such organizations of employees as may be recommended for the purpose by the State Government;

(f) an official of the Corporation to be nominated by the Director-General, who shall also act as Secretary to the Committee :

PROVIDED that where the Chairman, Regional Board, so considers it to be expedient, he may nominate such additional representatives of employers and employees, not exceeding two from each side, with a view to providing for the adequate representation of important organizations not included in the nominations of the State Government and to maintaining the parity between the number of representatives of such employers and employees:

PROVIDED FURTHER that in any area in which medical care is provided through a panel system, a local committee may co-opt a member representing the local insurance medical practitioners.

(2) (i) The term of office of the members of a local committee nominated under clauses (d) and (e) of sub-regulation (1) shall be [three years], commencing from the date on which their nomination is notified, provided that such members shall, notwithstanding the expiry of the said period, continue to hold office until the nomination of their successor is notified.

(ii) The members of a local committee nominated under clauses (b), (c) and (f) of sub-regulation (1) shall hold office during the pleasure of the authority nominating them.

(3) A member of a local committee may resign his office by notice in writing to the Chairman, Regional Board, and his seat shall fall vacant on the acceptance of the resignation.

(4) (i) A member of a local committee shall cease to be a member of the committee if he fails to attend three consecutive meetings thereof provided that his membership may be restored by the Chairman, Regional Board, on being satisfied as to the unavoidable nature of the circumstances which led to his non-attendance.

(ii) Where in the opinion of the State Government any person nominated to represent employers or employees on a local committee has ceased to represent such employers or employees, the Chairman, Regional Board, may declare that such person shall cease to be a member thereof with effect from such date as may be specified by him.

(5) The members of the committee shall receive such fees and allowances as may be specified by the Central Government.

(6) The Secretary, shall, in consultation with the Chairman, fix the date, time and place, of, and also draw up the agenda for every meeting. Notice of not less than seven days shall ordinarily be given to every member for such meeting. No matter other than that included in the agenda shall be considered except with the permission of the Chairman.

(7) No business shall be transacted at any meeting of a committee unless there is a quorum of not less than one-third of the number of the members of the committee.

(8) All matters at a meeting of a local committee shall be decided by a majority of persons present at the meeting and voting, and in case of equality of votes, the Chairman shall have a casting vote or a second vote.

(9) A local committee shall perform the following functions in respect of the area for which it is set up, namely-

(a) to discuss local problems in regard to the Employees' State Insurance Scheme so as to secure its efficient working with the full co-operation of all parties concerned and to make recommendations;

(b) to refer such complaints as it may consider necessary to the Regional Director concerned, or in the case of complaints concerning medical benefit, to the State Government or such authority as that government may nominate for the purpose; and

CHAPTER II

Collection Of Contributions,Etc

10B. Registration of factories or establishments.-(1) The employer in respect of a factory or an establishment to which the Act applies for the first time and to which an employer's code number is not yet allotted and the employer in respect of a factory or an establishment to which the Act previously applied but has ceased to apply for the time being, shall furnish to the appropriate regional office not later than 15 days after the Act becomes applicable, as the case may be, to the factory or establishment, a declaration or registration in writing in Form 01 (hereinafter referred to as Employer's Registration Form).

(b) The employer shall be responsible for the correctness of all the particulars and information required for and furnished on the employer's registration form.

(c) The appropriate regional office may direct the employer who fails to comply with the requirements of paragraph (a) of this regulation within the time stated therein, to furnish to that office employer's registration form duly completed within such further time as may be specified and such employer shall, thereupon, comply with the instructions, issued by that office in this behalf.

[(cc) The employer in respect of a factory or establishemnt to whcih a code number has been issued by the Corporation based on information collected or decision taken regarding applicability of the Act to such factory or establishment, shall, within fifteen days of receipt of information of allotment of code numet, furnish a decalaration in Form 01.]

(d) Upon receipt of the completed employer's registration form, the appropriate Regional Office shall, if satisfied that the factory or the establishment is one to which the Act applies, allot to it an employer's code number (unless the factory or the establishment has already been allotted an Employer's Code Number) and shall inform the employer of that number.

(e) The employer shall enter the employer's code number on all documents prepared or completed by him in connection with the Act, the rules and these regulations and in all correspondence with the appropriate office.

[10-C. Intimation regarding change in particulars submitted at the time of registration of factories/establishments - The employer in respect of a factory or establishment to whcih this Act applies and to whom a code number has already been allotted, shall furnish to the appropriate Regional Office or Sub-Regional Office of Divisional Office, any change in the particulars furnished in Form 01 at the time of registration of the factory / establishment within two weeks of such change.]

Declaration by persons in employment on appointed day -The employer in respect of a factory or an establishment shall require every employee in such factory or establishment to furnish and such employee shall on demand furnish to him either before or on the appointed day correct particulars required for the purpose of Form 1 (hereinafter referred to as the Declaration Form). Such employer shall enter the particulars in the Declaration Form including the temporary Identification Certificate, and obtain the signature or the thumb-impression of such employee and also complete the form as indicated thereon.
Declaration by persons engaged after the appointed day -(1) The employer in respect of a factory or an establishment shall, before taking any person into employment in such factory or establishment after the appointed day, require such person (unless he can produce an Identity Card or other document in lieu thereof issued to him under these regulations) to furnish and such person shall on demand furnish to him correct particulars required for the Declaration Form including the Temporary Identification Certificate. Such employer shall enter the particulars in the Declaration Form including the Temporary Identification Certificate and obtain the signature or the thumb-impression of such person and also complete the form as indicated thereon.

(2) Where an Identity Card is produced under such sub-regulation (1), the employer shall make relevant entries thereon.

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Declaration form to be sent to appropriate office -The employer shall send to the appropriate office by registered post or messenger, all declaration forms without detaching the temporary identification certificate prepared under these regulations together with a return in duplicate in Form 3 within 10 days of the date on which the particulars for the declaration forms were furnished
Allotment of insurance number -On receipt of the return required under regulation 14, the appropriate office shall promptly allot an insurance number to each a person in respect of whom the Declaration Form has been received unless it finds that the person had already been allotted an insurance number. The temporary identification certificate with insurance numbers marked thereon shall be detached and returned to the employer along with one copy of Form 3. The employer shall deliver the temporary identification certificate to the employee to whom it relates, after obtaining his signature or thumb-impression thereon except in the case of an employee to whom a certificate of employment has been issued under Regulation 17A. The Insurance Number allotted by the regional office to an employee and indicated in the copy of Form 3 returned to the employer, shall be entered by the employer on the [register of employees [Form 6][and return of contribution.]

15A. Registration of families -On the issue of notification under regulation 95A, specifying the date from which the family of an insured person shall also be entitled to medical benefit under the Act, every insured person who has not furnished the particulars of his family at the time of his registration under the Act, shall furnish to the employer correct particulars in respect of his family in Form 1A. The employer shall enter the particulars in the form and obtain the signature or the thumb-impression of such person and complete the form as indicated thereon and send it to the appropriate office within 10 days of the date on which the particulars were furnished.

15B. Changes in family -An insured person shall intimate all changes in the membership of the family as defined under the Act, to the employer within 15 days of such change having occurred and the employer shall enter such particulars in [Form 2] and shall forward it to the appropriate office within 10 days of the date on which the particulars were furnished.

Corporation to receive assistance from employers -An employer shall render all necessary assistance which the Corporation may require in connection with the registration of his factory or establishment and the registration of his employees and specially for photographing such employees and affixing the photographs to the identity cards.
Identity cards -The appropriate office shall arrange to have an identity card prepared in Form 4 for each person in respect of whom an insurance number is allotted and shall include in such card the particulars of the family entitled to medical benefit under regulation 95A and shall send all such identity cards to the employer. Such employer shall if and when the employee has been in his service for [3 months], obtain the signature or thumb-impression of the employee on the identity card and shall after making relevant entries thereon, deliver the identity card to him. The employer shall obtain a receipt from the employee for the identity card. The identity card in respeect of an employee who has left employment before [3 months]shall not be given to him, but shall be returned to the appropriate office a soon as possible. [The identity card shall not be transferable].

17A. Issue of a certificate of employment.-If an insured person happens to need medical care before the temporary identification certificate is issued to him, the employer shall issue a certificate of employment in such form as may be specified by the Director General to such person on demand. Such certificate shall also be issued on demand, if an insured person loses his temporary identification certificate before the receipt of the identity card.

17B. Issue of permanent acceptance card -In areas where the Director General considers it appropriate, the appropriate Office shall also supply a permanent acceptance card for each employee in such form as the Director General may specify along with the identity card and this shall also be delivered to the employee. Permanent acceptance card for the employee who has left employment before [3 months] shall not be given to him but returned to the appropriate office along with the identity card as soon as possible.

Loss of identity card -In case of loss, defacement or destruction of an identity card, the insured person shall report the matter to the appropriate [Branch office], and the Corporation may issue a duplicate copy of the identity card subject to such conditions and payment of such fees as may be determined by the Director-General.

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[26. Return of contributions to be sent to appropriate office .-(1) Every employer shall send a return of contributions in quadruplicate in [Form 5][along with receipted copies of challans for the amounts deposited in the Bank, to the appropriate office by registered post or messenger, in respect of all employees for whom contributions were payable in a contribution period, so as to reach that office as-

11[(a) within 42 days of the termination of contribution period to which it relates;

(b) within 21 days of the date of permanent closure of the factory or establishment, as the case may be];

[(1-A) Every employer shall be required to submit details in Form 5 (Return of Contribution) with regard to employees e4ngaged through Principal and Immediate Employers and their coverage, submission of Declaration Forms, distribution of Temporary Identification Certificates/Permanent Identity Cards and wages considered for payment of contribution and wages excluded for such purpose.]

2. For the purposes of section 77 of the Act, the due date by which the evidence of contributions having been paid must reach the Corporation shall be the last of the days respectively specified in clauses (a), (b) and (c) of sub-regulation (1).]

[27. Issue of certificate of contributions .-An employer shall, on demand from the appropriate office, issue certificate of contributions paid or payable in respect of an insured person in such form as may be specified by the Director General.]

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[29. Payment of contribution -Contribution payable under the Act shall, except when otherwise provided, be paid into a Bank duly authorized by the Corporation].

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[31. Time for payment of contribution -An employer who is liable to pay contributions in respect of any employee shall pay those contributions within [15 days] of the last day of the calendar month in which the contributions fall due];

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

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

[31A. Interest on contribution due, but not paid in time -An employer who fails to pay contribution within the periods specified in regulation 31, shall be liable to pay [simple interest at the rate of [twelve per cent][per cent per annum] [in respect of each day of default or delay in payment of contribution.]

[31B. Recovery of interest -Any interest payable under regulation 31A may be recovered as an arrear of land revenue or under section 45C to section 45-I of the Act.]

[31C. Damages or contributions or any other amount due, but not paid in time .-An employer who fails to pay contributions within the periods specified under regulation 31, or any other amount payable under the Act, shall be liable to pay damages as under:

Period of delay	Maximum rate of damages in per cent per annum of the amount due
(i) Less than 2 months	5%
(ii) 2 months and above but less than 4 months	10%
(iii) 4 months and above but less than 6 months	15%
(iv) 6 months and above	25%

PROVIDED that the Corporation, in relation to a company in respect of which a Resolution Plan has been sanctioned by the National Company Law Tribunal under the Insolvency and Bankruptcy Code, 2016, may-

(a) Waive up to 50 percent of the damages levied or leviable depending upon merits of the case.

(b) in exceptional hard cases, waive either totally or partially the damages levied or leviable.]

[31-D. Appellate Authority.- The Appellate Authority under section 45-AA of the Act shall be the Insurance Commissioner, the Additional Commissioner, Regional Director and Joint Director.

31-E. Interest on amounts refunded to the employer.- If an employer finally succeeds in the appeal under section 45-AA, The amount deposited by him with the corporation, in full or part, as per decision of the Appellate Authority, shall be refunded to him along with simple interest at the rate specified in regulation 31-A]

[32. Register of employees engaged by immediate employer -(1) Every immediate employer shall maintain a register in [Form 6][in respect of every employee of his factory or establishment.]

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

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

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

Other modes of payment of contribution -Subject to the directions of the Standing Committee, the Director-General may, if he thinks fit and subject to such terms and conditions as he may impose, approve of any arrangement, [* * *], whereby contributions are paid at times or in a manner other than those specified in these regulations and such arrangement may include provision for the payment to the Corporation of such fees as may be determined by him to represent the estimated additional expenses to Corporation, and may require such deposit of money by way of security as he may determine.

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[36. Employment for part of a wage period -Where an employee is employed by an employer for part of a wage period, the contributions in respect of such wage period, shall fall due on the last day of the employment by such employer in that wage period.]

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Scheme by joint employers -Where an employee is ordinarily employed by two or more employers in a [wage period]the employers of such an employee may, if they think fit, submit to the Corporation a scheme for the payment of the contributions in respect of such employee and the Corporation may, if it is satisfied that the scheme is such as will secure the due payment of the contributions, approve such a scheme subject to such terms and condition as it may think necessary:

PROVIDED that if no such scheme is submitted to or approved by the Corporation, the Corporation may specify that any one of such employers shall be treated as the employer for the purposes of the provisions of the Act and the regulation relating to contributions, and in such a case the contribution for any [wage period] shall fall due on the last day of the [wage period] on which an employee was employed by the employer so specified.

Reckoning of wages of employee employed by two or more employers in the same[wage period].-

Where an employee is employed by an employer for only a part of the [wage period] or where an employee by an employed by two or more employers in a [wage period], only the wages payable to him for the days up to and including the day on which the contribution falls due for that [wage period] shall be taken into account in reckoning wages for the purposes of determining the average daily wages of the employee for that [wage period].

40.Refund of contribution erroneously paid -(1) Any contribution paid by a person under the erroneous belief that the contributions were payable by that person under the Act may be refunded without interest by the Corporation to that person, if application to that effect is made in writing before the commencement of the benefit period corresponding to the contribution period in which such contribution was paid.

(2) Where any contribution has been paid by a person at a rate higher than that at which it was payable the excess of the amount so paid over the amount payable may be refunded without interest by the Corporation to that person, if application to that effect is made before the commencement of the benefit period corresponding to the contribution period in which such contribution was paid.

(3) In calculating the amount of any refund to be made under this regulation there may be deducted the amount, if any, paid to any person by way of benefit on the basis of the contribution erroneously paid and for the refund of which the application is made.

(4) Where the whole or part of the amount of any contribution referred to in sub-regulations (1) and (2), was recovered from an immediate employer or deducted from the wages of an employee by the principal employer, he shall, on getting the refund of the amount due from the Corporation, be liable to pay back the amount so recovered or deducted to the person from whom the amount was so recovered or deducted.

(5) Applications for refund under this regulation shall be made in such form and in such manner and shall be supported by such documents as the Director-General may, from time to time, determine

41.[***]

42.[***]

43.[***]

CHAPTER-III

Benefits

Claims

Claims for benefits -Every claim for a benefit payable under the Act shall be made in writing, in accordance with these regulations, to the appropriate [Branch Office]on the form appropriate for the purpose of the benefit for which the claim is made or in such other manner as the appropriate office may, subject to its being in writing, accept as sufficient in the circumstances of any particular case or class of cases. Assistance for filling in the form of claim in case of insured persons who cannot do so themselves shall be provided at the [Branch Office]of the Corporation.

[Provided that in case of permanent disablement benefit and dependants benefit, claim shall be required to be made only for the first payment and no claim shall be required for subsequent periodical payments.]

When claim becomes due -A claim for any benefit under the Act shall for the purposes of section 77 of the Act, become due on the following days-

(a) For sickness benefit or for disablement benefit for temporary disablement for any period, on the date of the issue of the medical certificate in respect of such periods; provided that in cases where a person is not entitled to sickness benefit for the first two days of sickness, the due date shall be deferred by such days.

(b) For maternity benefit-

(i) in case of confinement, on the date of issue, in accordance with these regulations, of certificate of excepted confinement or on the day six weeks preceding the expected date of confinement so certified whichever is later or, if no such certificate is issued, on the date of confinement; and

(ii) in case of miscarriage and in case of sickness arising out of pregnancy, confinement, premature birth of child or miscarriage, on the date of issue of the medical certificate of such miscarriage or sickness, as the case may be;

(c) for first payment of disablement benefit for permanent disablement, on the date in which an insured person is declared as permanently disabled in accordance with the Act and these regulations; and

(d) for first payment of dependants' benefit, on the date of the death of the insured person in respect of whose death, the claim for such benefit arises or, where disablement benefit was payable for that date, on the date following the date of death or, where the beneficiary becomes entitled to a claim on any subsequent date, on the date on which he becomes so entitled;

(e) for subsequent payments of disablement benefit for permanent disablement and for subsequent payment of dependant's benefit, the last day of the month to which the claim relates;

(f) for [funeral expenses] on the date of the death of the insured person in respect of whose death the claim for such benefit arises.

Availability of claim forms -Claims forms shall be available to intending claimants from such persons and such offices of the Corporation as it may appoint or authorize for the purpose, and shall be supplied free of charge.
Claim on wrong form -Where a claim for any benefit has been made on an approved form other than the form appropriate to the benefit claimed, the Corporation may treat the claim as if it was made on the appropriate form:

PROVIDED that the Corporation may in any such case require the claimant to complete the appropriate form.

Evidence in support of claim -Every person who makes a claim for any benefit shall, in addition to the medical certificate and other forms specifically required under these regulations, furnish such other information and evidence for the purpose of determining the claim as may be required by the appropriate office, and, if reasonably so required, shall for that purpose attend at such office or place as the appropriate office may direct
Defective claim -If, in the absence of due signature or of due certification, a claim is defective on the date of its receipt by an office of the Corporation, the office of the Corporation may in its discretion refer the claim to the claimant and if the form is returned duly signed and/or certified within three months from the date on which it was so referred, the office may treat the claim as if it had been duly made in the first instance.
Claim for inappropriate benefit- Where it appears that a person who has made a claim for any benefit payable under the Act, may be entitled to a benefit other than that which he has claimed, any such claim may be treated as a claim in the alternative for that other benefit.
Authority for certifying eligibility of claimants.-The authority which is to certify the eligibility of claimants shall be the appropriate [Branch Office]in respect of maternity, sickness, temporary disablement benefit [benefits and funeral expenses]and the appropriate Regional Office, in respect of permanent disablement and dependant's benefits.
Benefits when payable.-[(1) Any benefit payable under the Act shall be paid

(a) in the case of sickness benefit not later than 7 days;

4 [(b) in the case of funeral expenses not later than 15 days;]

[(c) in the case of the first payment in respect of maternity benefit not later than 14 days;

(d) in the case of the first payment in respect of Temporary Disablement Benefit not later than one month;

(e) in the case of the first payment of Permanent Disablement Benefit not later than one month;

(f) in the case of first payment of Dependants' Benefits not later than 3 months, after the claim therefore together with the relevant medical or other certificates and any other documentary evidence which may be called for under these regulations has been furnished complete in all particulars to the appropriate office.]

(2) Second and subsequent payments in respect of any maternity, temporary disablement, permanent disablement or dependants' benefit shall be paid alongwith the first payment in respect thereof or within the calendar month following the month to the whole or part of which they relate, whichever is later subject to production of any documentary evidence which may be required under these regulations.

(3) Where a benefit payment is not made within the time limits specified in sub-regulations (2) and (3) above, it shall be reported to the appropriate Regional Office and shall be paid as soon as possible.

(4) Benefits under the Act shall be paid in cash at a '[Branch Office] on such days and working hours as may be fixed by the Director-General or such other officer of the Corporation, as may be authorised by him from time to time in this behalf, or, at the option of the claimant and subject to deduction of the cost of remittance, by means of postal money orders or other orders payable through a post office, or by any other means which the appropriate office may in the circumstances of any particular case consider appropriate:

Provided that the Corporation may waive the deduction of the cost of remittance in each cases as the Director-General may, from time to time, specify.

(5) Where the payment of a benefit is to be made at a [Branch Office],such'-office may insist upon the production of the Identity Card or other document issued in lieu thereof in respect of the insured person.

[52-A. Abstention verification.-[(1)][Every employer shall furnish to the appropriate Office such information and particulars in respect of the abstention of an insured person for work for which sickness benefit [* * *][or disablement benefit for temporary disablement, as provided under the Act have been claimed or paid, in [Form 10][and within such time as the said office may in writing require in the said Form.]

[(2) Every employer shall furnish to the appropriate office such information and particulars in respect of the abstention of an insured woman from work for which maternity benefit as provided under the Act has been claimed or paid, in [Form 10] [and within such time as the said office may in writing require in the said Form.]

Certification and claims for sickness and temporary disablement

Evidence of sickness and temporary disablement.-Every insured person, claiming sickness benefit or disablement benefit for temporary disablement, shall furnish evidence of sickness or temporary disablement in respect of the days of his sickness or temporary disablement by means of a medical certificate given by an Insurance Medical Officer in accordance with these regulations in the form appropriate to the circumstances of the case:

Provided that in areas where arrangements for medical benefit under the Employees' State Insurance Act have not been made or otherwise if in its opinion the circumstances of a particular case so justify, the Corporation may accept any other evidence of sickness or temporary disablement in the form of a certificate issued by the medical officer of the State Government, local body or other medical institution, or a certificate issued by any registered medical practitioner containing such particulars and attested in such manner as may be specified by the Director-General in this behalf.

Persons competent to issue medical certificate.-No medical certificate under these regulations shall be issued except by the Insurance Medical Officer to whom an insured person has been allotted or by an Insurance Medical Officer attached to a dispensary, hospital, clinic or other Institution to which an insured person is allotted and such Insurance Medical Officer shall examine and if in his opinion the condition of the insured person so justifies, issue to such insured person free of charge, any medical certificates reasonably required by such insured person under or for the purposes of the Act or any other enactment or these regulations:

Provided that an Insurance Medical Officer may issue a medical certificate under these regulations to an insured person who is not allotted to him or to the dispensary, hospital, clinic or other institution to which he is attached, if such officer is satisfied that in the circumstances of any particular case the insured person cannot reasonably be expected to get medical benefit from the Insurance Medical Officer or the dispensary, hospital, clinic or other institution to which such insured person has been allotted ; and such certificate shall also be issued free of charge:

Provided further that an insured person shall not be granted a medical certificate unless he produces to the Insurance Medical Officer his Identity Card or such other "Documents" as under these regulations, may have been issued in lieu thereof.

Medical certificate.-The appropriate form of a medical certificate shall be filled in ink or otherwise as may be specified by the Director-General, by the Insurance Medical Officer in his own handwriting and shall contain a concise statement of the disease or disablement which in the opinion of the Insurance Medical Officer necessitates abstention from work on medical grounds or renders the person temporarily incapable of work. The statement of the disease or disablement in the medical certificate shall specify the nature thereof as precisely as the Insurance Medical Officer's knowledge of the condition of the insured person at the time of the examination permits.
Time of granting medical certificate.-(a) An Insurance Medical Officer shall give the medical certificate to an insured person at the time of the examination to which it relates; where he is prevented from so doing he shall send the certificate to the insured person within twenty-four hours thereafter.

(b) No further medical certificate relating to the same examination shall be issued, except where a duplicate of such certificate is required, in which case it shall be issued free of charge and clearly marked "Duplicate".

Medical certificate on first examination.-When the examination is the first examination in respect of a spell of sickness or a spell of temporary disablement, the medical certificate shall be in the form of a first certificate [Form 7]and shall be only in respect of the date of examination:

Provided that where the insured person who needs abstention from work on the day of examination, states that he has been actually sick or temporarily disabled on a day earlier than the date of his first examination, the Insurance Medical Officer may, if he is satisfied as to the truth of the statement that the insured person was unable to present himself for medical examination earlier for reasons beyond his control, certify incapacity for work on the date preceding the date of examination:

Provided further, that where in the opinion of the Insurance Medical Officer, the insured person is likely to become fit to resume work on a date not later than the third day after the date of examination, the first certificate may be issued in respect of the entire spell of sickness or temporary disablement, and, in such a case, it shall specify the date on which the insured person will, in his opinion, be fit to resume work; such a certificate shall, notwithstanding anything contained in the regulations, be also treated as a final certificate.

Final medical certificate.-If at the date of the examination to which amedical certificate other than a first certificate relates, the insured person in the opinion of the Insurance Medical Officer is, or will become on a date not later than the third day after that date, fit to resume work, that certificate shall be in the form of a final certificate [Form 7].
Intermediate certificate.-If the final certificate is not issued within seven days of the date of the first certificate, an insured person shall, except where the case is covered by regulation 61, submit certificates in the form of intermediate certificates [Form 7]at intervals of not more than seven days each, commencing from the date of the first certificate.
Final medical certificate before commencing work for wages.-Every insured person shall obtain a medical certificate in the form of a final certificate before he takes up any work for wages.
Intermediate certificate for a longer period.-When temporary disablement or sickness has continued for not less than twenty-eight days and the Insurance Medical Officer is satisfied that such disablement or sickness is likely to continue for a long period and that, owing to the nature of the disablement or sickness examination and treatment at intervals of more than one week will be sufficient, the insured person may, unless otherwise directed by the appropriate office, furnish medical certificates in the form of special intermediate certificates [Form 8]at intervals of such longer periods not exceeding four weeks as may be specified by the Insurance Medical Officer.

62.[* * *]

Form of claim for sickness or temporary disablement.-An insured person intending to claim sickness benefit or disablement benefit for temporary disablement shall submit to the appropriate[Branch Office]by post or otherwise, a claim for benefit in [Form 9], appropriate to the circumstances of the case together with the appropriate medical certificate:Provided that where only one claim in [Form 9]is submitted in respect of more than one certificates, such [Form 9] shall be deemed to be appropriate to all such certificates.
Failure to submit medical certificate.-If a person who intends to claim sickness benefit or disablement benefit for temporary disablement fails to submit to the appropriate [Branch Office]by post or otherwise the first medical certificate or any subsequent medical certificate within a period ofthree days from the date of issue of such certificate he shall not be eligible for that benefit in respect of any period

(i) in the case of a first certificate, more than three days before the date on which the certificate is submitted to the appropriate [Branch Office];

(ii) in the case of a subsequent certificate, more than fourteen days before the date on which such subsequent certificate is submitted to the appropriate [Branch Office]:

Provided that the appropriate Regional Office or other office as authorised by the Director-General may relax all or any of the provisions of this regulation in any particular case, if it is satisfied that the delay in submitting a certificate was due to bona fide reasons.

Disablement benefit

Notice of accident.-(i) Every [employee] who sustains personal injury caused by accident arising out of and in the course of his employment in a factory or establishment shall give notice of such injury either in writing or orally, as soon as practicable after the happening of the accident:

Provided that any such notice required to be given by an [employee] may be given by some other person acting on his behalf.

Explanation.-No such notice shall be required to be given by an [employee] if an employment injury is caused by any Occupational Disease specified in Schedule III to the Workmen's Compensation Act, 1923 (8 of 1923).

(ii) Every such notice shall be given to the employer or to a foreman or to other official under whose supervision the [employee] is employed at the time of the accident or any other person designated for the purpose by the employer and shall contain the appropriate particulars.

(iii) Any entry of the appropriate particulars of the accident made in a book kept for that purpose in accordance with the next following regulation shall, if made as soon as practicable after the happening of the accident by the [employee] or by some other person acting on his behalf, be sufficient notice of the accident for the purpose of these regulations.

(iv) In this regulation and the next following regulation, the expression "appropriate particulars" means the particulars indicated below:

(a) full name, Insurance number, sex, age, address, occupation, department and shift of the injured person;

(b) date and time of accident;

(d) cause and nature of injury;

(e) name, address and occupation of the person giving the notice, if he is other than the injured person;

(f) a statement of what exactly the injured person was doing at the time of injury;

(g) name, addresses and occupation of two persons who were present at the spot when accident happened; and

(h) remarks, if any.

Maintenance of accident book.-Every employer shall,- _

(i) keep a book readily accessible (hereinafter called "the Accident Book") in [Form 11], in which the appropriate particulars of any accident causing personal injury to an [employee] may be entered;

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

Provided that it shall not be necessary to enter in the said Accident Book particulars of any employment injury caused by an occupational disease specified in Schedule III to the Workmen's Compensation Act, 1923 (8 of 1923).

Notice otherwise than by an entry in accident book.-If notice of an employment injury under regulation 65 is given otherwise than by an entry in the accident book it shall be the duty of the employer or any other person to whom such notice is given under that regulation to make an appropriate entry in the book in respect of the accident to which the notice relates immediately after such notice is received, and where the notice is received otherwise than in writing, read over the particulars to the person who gives the notice and obtains his signature or thumb-impression on the accident book.
Report of accident by an employer.-Every employer shall send a report in [Form 12]to the nearest [Branch Office]and to the nearest Insurance Medical Officer

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

(ii) in any other case within 24 hours after the receipt of the notice under regulation 65 or of the time when the accident came to the notice of the employer or of a foreman or other official under whose supervision the insured person was employed at the time of the accident or any other person designated for the purpose by the employer:

Provided that in case of a serious injury, and particularly when the injury results in death at the place of employment, the report to the Insurance Medical Officer and the [[Branch Office] shall be sent through a special messenger, or otherwise, as speedily as may be practicable under the circumstances:

Provided further that where a report of the accident is made by the employer under the Factories Act, 1948 (63 of 1948), the report to the [Branch Office] and to the Insurance Medical Officer may be made in the same form as is prescribed under the Factories Act, 1948 (63 of 1948), provided that all the additional information required under [Form 12] is added thereto:Provided further that it shall not be necessary for the employer to send a report in [Form 12] if an employment injury is caused by an Occupational Disease specified in Schedule III to the Workmen's Compensation Act, 1923 (8 of 1923); but the employer shall furnish on demand to the appropriate [Branch Office], within such reasonable period as may be specified, suchinformation and particulars as shall be required of the nature of and other relevant circumstances relating to any employment specified in Schedule III to the Workmen's Compensation Act, 1923 (8 of 1923).

Employer to arrange first aid.-Every employer shall arrange for such first aid and medical care and transport for obtaining such aid and care as the circumstances of the accident may require till the injured person is seen by the Insurance Medical Officer and such employer shall be entitled to reimbursement in respect of expenses thereby incurred by him but not exceeding such scale of expenses as may be specified by the Corporation from time to time:

Provided that if the employer is required to provide such medical aid free of charge under any other enactment, he shall not be entitled to any reimbursement of expenses.

Employer to furnish further particulars of accident.-Every employer shall furnish to the appropriate office such further information and particulars of an accident and within such time as the said 6ffice may, in writing, require.
Directions by the Corporation.-Every claimant for and every beneficiary in receipt of disablement benefit shall comply with every direction given to him by the appropriate Regional Office which requires him either

(i) to submit himself to a medical examination by such medical authority as may be appointed by that office for the purpose of determining the effect of the relevant employment injury or the treatment appropriate to the relevant injury or loss of faculty, or

(ii) to attend any vocational training courses or industrial rehabilitation courses provided by any institution maintained by any Government, local authority or any public or private body, recognised for the purpose by the Corporation and considered appropriate by it in his case.

Reference to a Medical Board.-A reference to the Medical Board may, be made,

[(a) at any time not later than twelve months, in cases where claim for temporary disablement benefit is made for an employment injury, from the date of the final certificate issued in respect of the spell of temporary disablement commencing on or immediately after the day of the occurrence of that injury, or from the date of the occurrence of an employment injury in cases where temporary disablement benefit not having been claimed, claim for permanent disablement is made on the basis thereof by the appropriate Regional Office at the instance of the disabled person or the employer or any recognised employees' union:

Provided that such reference may be made by the appropriate Regional Office after the expiry of the period prescribed as aforesaid if it is satisfied that the applicant was prevented by sufficient cause from applying for the making of the reference in time:

Provided further that in the event of the claim for Temporary Disablement Benefit being rejected by the Corporation but afterwards granted by the Employees' Insurance Court in respect of injuries resulted in Permanent Disablement, the limit of 12 months will apply from the date of the order of the Employees' Insurance Court granting the claim of the insured person for Temporary Disablement Benefit, or]

(b) by the Corporation,

(i) at any time, on the recommendation of an Insurance Medical Officer, and

(ii) on its own initiative, after the expiry of the period of twenty-eight days from the first date on which the claimant was rendered incapable of work by the relevant employment injury.

Report of Medical Board.-The Medical Board shall after examining the disabled person send its decision on such form as may be specified by the Director-General, to the appropriate Regional Office. The disabled person shall be informed in writing of the decision of the Medical Board and the benefit, if any, to which the disabled person shall be entitled.
Occupational disease.-Any question whether an employment injury is caused by an occupational disease specified in the Third Schedule to the Act shall be determined by a Special Medical Board which shall examine the disabled person and send a report in such form as may be prescribed by the Director-General in this behalf to the appropriate Regional Office stating:

(a) whether the disabled person is suffering from one or more of the diseases specified in the said Schedule;

(b) whether the relevant disease has resulted in permanent disablement;

(d) the assessment of the proportion of loss of earning capacity and in case of provisional assessment, the period for which such assessment shall hold good.

All assessments which are provisional may be referred to the Special Medical Board for review by the appropriate Regional Office not later than the end of the period taken into account by the provisional assessment. Any decision of the Special Medical Board may be reviewed by it at any time. The disabled person shall be informed in writing of the decision of the Special Medical Board by the appropriate Regional Office and the benefit, if any, to which the insured person shall be entitled.

[75. Constitution of Medical Board/Special Medical Boards.-Medical Boards for the purposes of the Act and the Special Medical Boards for the purposes of regulation 74 shall be constituted by the Corporation and where it so desires it may approach the State Government for setting up the same and shall consist of such persons, havesuch jurisdiction and follow such procedure as the Director-General may from time to time decide.]

Appeal Tribunals.-For the purposes of regulation 74, an Appeal Tribunal shall be constituted by the State Government and shall Consist of a Judicial Officer of the State Government being a person other than the judge of an Employees' Insurance Court, Who shall be assisted by the following persons to be selected by him as assessors

(a) One or more medical experts;

(b) One or more officials of or members of Trade Union or Unions.

76-A. [Submission of claims for permanent disablement benefit].-Aninsured person who has been declared to be permanently disabled by a Medical Board or by an Appeal Tribunal shall submit, by post or otherwise, to the appropriate [Branch Office] [a claim, for receving the first payment of permanent disablement benefit in Form 14.]

[76-B. Commutation of permanent disablement benefit.-(1) An insured person whose permanent disablement has been assessed as final and who has been awarded permanent disablement benefit at a rate not exceeding [Rs. 10.00] [per day may apply for commutation of permanent disablement benefit into a lumpsum:

Provided that the insured person whose permanent disablement has been assessed as final and the benefit rate exceeds [Rs. 10.00][ per day may also apply for commutation of permanent disablement benefit into lumpsum subject to the condition that the total commuted value of the lumpsum permanent disablement benefit does not exceed [Rs. 60,000] [at the time of commencement of final award of his permanent disability:

Provided further that cases falling under clause (3) of this regulation where commutation has been refused because the insured person did not have average expectation of life, shall not be re-opened.]

(2) Where such an application is made within 6 months of the date on which he can opt for commutation hereafter called the "date of possible option" [permanent disablement benefit] shall be commuted into a lumpsum.

(3) Where such an application is made after expiry of six months from the date of possible option, the [permanent disablement benefit] may be commuted into a lumpsum if the Corporation is satisfied that the insured person has an average expectation of life for his age. For this purpose, the insured person shall, if so required by the appropriate office, present himself for examination by such medical authority as the Director-General may, by general or special order, specify.

(4) For the purpose of this regulation, the date of possible option shall mean

(i) in the case of a person who, on the date on which this regulation comes into force, is in receipt of permanent disablement benefit covered by sub-regulation (1) the date of coming into force of this regulation;

(ii) in the case of any other insured person, the date on which assessment of permanent disablement covered by sub-regulation (1), is communicated to him by the appropriate Regional Office.

(5) The amount of lump sum admissible under this regulation shall bedetermined by multiplying the daily sate of [permanent disablement benefit] by the figure indicated in Column `2 of Schedule III to these regulations, corresponding to the age on last birthday of the insured person on the date on which his application for commutation is received in the appropriate office and on and from the date ' [[the permanent disablement benefit] shall cease to be payable to him:

[Provided that where no proof of age has been submitted as required by the appropriate office or if submitted, has not been accepted as satisfactory by the appropriate offic'A, the corresponding age as aforesaid of the insured person shall be the age as estimated by the Medical Board on the date of examination adjusted by the period intervening between the date of examination by the Medical Board and the date on which the application for commutation was received in the appropriate office:

Provided further that the age so estimated by the Medical Board shall also operate against any proof of age that may be submitted after the time allowed for the purpose to the insured person by the appropriate office before reference of his case to the Medical Board.]

Dependants' benefit

Report of death of insured person by employment injury.-In case of death of an [employee] as a result of an employment injury

(a) if the death occurs at the place of employment the employer shall, and

(b) if the death occurs at any other place, a dependant intending to claim dependants' benefit shall, or

(c)any other person present at the time of death may,immediately report the death to the nearest[Branch Office] and to the nearest dispensary, hospital, clinic or other institution where medical benefit under the Act is available.

Disposal of body of an [employee] dying by employment injury.-Where an [employee] dies as a result of an employment injury sustained as an employee under the Act, the body of the [employee] shall not be disposed of until the body has been examined by an Insurance Medical Officer, who will also arrange a post-mortem examination, if considered necessary, in co-operation with any other existing agency:

Proy.ided that if an Insurance Medical Officer is unable to arrive for the examiri:ation within 12 hours of such death, the body may be disposed of after obtaining a certificate from such Medical Officer or practitioner as may be available:

Provided further that nothing contained in this regulation shall be in derogation of any power conferred on a Coroner under any law for the time being in force or on the officer-in-charge of a police station or some other police officer under [section 174 of the Code of Criminal Procedure, 1973 (2 of 1974)].

Issue of death certificate.-An Insurance Medical Officer attending thedisabled person at the time of his death or the Insurance Medical Officer who examines the body after the death or the Medical Officer who attended the insured person in a hospital or other institution where such disabled person died, shall issue free of charge a death certificate in [Form 13]to the dependants of the deceased and shall send a report to the appropriate Regional Office.
Submission of claim for dependants' benefit.-(1) A claim for dependants' benefit shall be submitted to the appropriate [Branch Office]by post or otherwise in [Form 15]by the dependant or dependants concerned or by their legal representative or, in case of a minor, by his guardian, and such claim shall be supported by documents proving

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

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

(iii) the age of the claimant;

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

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

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

(a) certified extract from an official record of births showing the date and place of birth and father's name;

(b) original horoscope prepared soon after birth;

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

(e) such other evidence as may be acceptable to the appropriate Regional Office in the circumstances of a particular case.

Notice for dependants' benefit.-On receipt of a claim or claims for dependants' benefit in respect of the death of an [employee] and, after making such inquiries as may be necessary about the circumstances and cause of death and about all persons who may be entitled to dependants' benefit, the appropriate Regional Office shall issue by registered post to such other persons, if any, as appear on enquiry to be entitled to dependants' benefit, and who have not yet submitted a claim for such benefit a notice for submission of claims for dependants' benefit within a period of thirty days from the date ofsuch notice. The notice shall indicate inter alia the relevant provisions of the Act and regulations and the procedure for submission of a claim for dependant's benefit.
Intimation of decision regarding dependants' benefit.-As soon as possible after the expiry of the period during which claims can be submitted in terms of the notice issued under regulation 81, the appropriate Regional Office shall intimate by registered post the decision of the Corporation in regard to the claim of each of the dependants in writing to the dependants concerned or to his legal representative, or, in the case of a minor, to his guardian.
Date of accrual of dependant's benefit.-The dependant's benefit shall accrue from the date of the death in respect of which the benefit is payable, or, where disablement benefit was payable for that date from the date following the date of death.

83-A. Submission of claims for dependants' benefit.-Each dependant whose claim for dependants' benefit is admitted under regulation 82, shall submit to the appropriate [Branch Office], by post or otherwise, [a claim for receiving first payment of dependents, benefit in Form 16]. Such claim may be made by the legal representative of a beneficiary or in the case of a minor by his guardian.

Review of dependant's benefit.-(1) The amounts payable as dependant's benefit in respect of the death of any insured person may be reviewed by the appropriate Regional Office at its own initiative, and shall be so reviewed if an application is made to that effect, under any of the following circumstances

(a) if any of the beneficiaries ceases to be entitled to the dependant's benefit by reason of marriage, re-marriage, death, age or otherwise, or

(b) if a fresh dependant is admitted to the claim for dependant's benefit by the birth of a posthumous child, or

(c) if, after the previous decision as to the distribution of the dependants' benefit was taken, some facts materially affecting such distribution come to light.

(2) Any review under this regulation shall be made after giving due notice by registered post to each of the dependants, stating therein the reasons for the proposed review and giving them an opportunity to submit objections, if any, to such review.

(3) Subject to the provisions of the Act and these regulations, the appropriate Regional Office may, as a result of such review, commence, continue, increase, reduce or discontinue from such date as it may decide the share of any of the dependants.

85.[* * *]

Appointment of another guardian.-If at any time the appropriate Regional Office is satisfied that a child who is in receipt of dependant's benefitis being neglected by his guardian, not being a guardian appointed under the Guardian and Wards Act, 1890 (8 of 1890); and the child's share of the dependant's benefit is not being properly spent on his or her maintenance, the appropriate Regional Office may direct that such share may be paid subject to such conditions as it may specify to such other person as it deems fit and as in its opinion would utilise it for the care and maintenance of the child.

Maternity benefit

Notice of pregnancy.-An insured woman, who decides to give notice of pregnancy before confinement, shall give such notice in [Form 17]to the. appropriate [Branch Office]by post or otherwise and shall submit, together with such notice, a certificate of pregnancy in [Form 17] given in accordance with these regulations on a date not earlier than seven days before the date on which such notice is given.
Claim for maternity benefit commencing before confinement.-Every insured woman claiming maternity benefit before confinement shall submit to the appropriate [Branch Office]by post or otherwise

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

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

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

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

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

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

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

Other evidence in lieu of a certificate.-The Corporation may accept any other evidence in lieu of a certificate of pregnancy, expected confinement, confinement death during maternity, miscarriage or sickness arising out of pregnancy, confinement, premature birth of child or miscarriage by an Insurance Medical Officer, if in its opinion, the circumstances of any particular case so justify.
Notice of work for remuneration.-Except as provided in regulation 89-B every insured woman who has claimed maternity benefit shall give notice in [Form 19]if she does work for remuneration on any day during the period for which maternity benefit would be payable to her but for her working for remuneration.
Date of payment of maternity benefit.-Maternity benefit shall be payable from the date from which it is claimed provided that such date does not precede the expected date of confinement by more than forty-two days, and that no work is undertaken by the insured woman for remuneration.
Disqualification for maternity benefit.-An insured woman may be disqualified from receiving maternity benefit if she fails without good cause to attend for or to submit herself to medical examination when so required; and such disqualification shall be for such number of days as may be decided by the authority authorised by the Corporation in this behalf:

Provided that a woman may refuse to be examined by other than a female doctor or midwife.

Authority which may issue certificate.-No certificate required under any of the regulations 87 to 89-B shall be issued except by the Insurance Medical Officer to whom the insured woman has or had been allotted or by an Insurance Medical Officer attached to a dispensary, hospital, clinic or other institution to which the insured woman is or was allotted and such Insurance Medical Officer shall examine and if in his opinion the condition of the woman so justifies or in case of death of the insured woman or the death of the child, if satisfied about such death, issue to such insured woman or in case of her death to her nominee or legal representative, as the case may be, free of charge any such certificate when reasonably required by such insured woman or her nominee or legal representative, as the case maybe, under or for the purpose of the Act or any other enactment or these regulations:

Provided that such Officer may issue a certificate, as aforesaid, under these regulations, to or in respect of an insured woman who is or was not allotted to him or to the dispensary, hospital, clinic or other institution to which such Officer is attached, if such Officer is attending the woman for prenatal care, for confinement, for miscarriage or for sickness arising out of pregnancy, confinement, premature birth of child or miscarriage or in case of death, was attending the deceased insured woman or the child at the time of the death of the insured woman or the child:

Provided further that a certificate of pregnancy, of expected confinement, of miscarriage required under these regulations may be issued by a Registered midwife which shall be accepted by the Corporation on counter-signature by the Insurance Medical Officer:

Provided that such Officer may issue a certificate of pregnancy, expected confinement or confinement under these regulations to an insured woman who is not allotted to him or to the dispensary, hospital, clinic or other institution to which such officer is attached, if such Officer is attending the woman for pre-natal care or for confinement:

Provided further that a certificate of pregnancy, of expected confinement or of confinement required under these regulations may be issued by a registered midwife which shall be accepted by the Corporation on counter-signature by the Insurance Medical Officer.

Obligations of Insurance Medical Officer.-Nothing in these regulations shall relieve an Insurance Medical Officer to whom an insured woman has been allotted, or an Insurance Medical Officer attached to the dispensary, hospital, clinic or other institution to which an insured woman is allotted, of the obligation to examine and if in her opinion the condition of the woman so justifies, issue free of charge a certificate of pregnancy, of expected confinement or confinement or miscarriage or of sickness arising out of pregnancy, confinement, premature birth of a child or miscarriage during any period in which such insured woman is obtaining treatment or attendance from any other person or from any other hospital or institution.

Medical benefit to families

95-A. Medical benefit to families of insured persons.-(l) Medical benefit may be extended to the families of insured persons from such date as the Corporation may, in consultation with State Government, notify.

(2) The family of an insured person shall become entitled to medical benefit [from the day the insured person himself] becomes entitled to medical benefit and shall continue to be so entitled so long as the insured person is entitled to receive medical benefit for himself, or in the case of death of the insured person till such date up to which the insured person would have remained entitled to medical care had he survived.

(3) The nature and scale of medical benefit to which the family of an insured person shall be entitled shall be such as may be specified by the State Government in consultation with the Corporation from time to time.

[(4) The appropriate office shall arrange to add in [Form 4-A][, the particulars of the family entitled to medical benefits.]

[* * *]

[Funeral expenses]

95-B. Report of death of insured person.-In case of death of an insured person

(a) if the death occurs at the place of employment, the employer shall, and

(b) if the death occurs at any other place, the person entitled and intending to claim [funeral expenses] shall, or

(c) any other person present at the time of death may,immediately report the death to the [Branch Office] of the deceased insured person.

95-C. Issue of death certificate.-An Insurance Medical Officer attending the insured person at the time of death or the Insurance Medical Officer who examines the body after the death or the Medical Officer who attended the insured person in a hospital or other institution where such insured person died, shall issue free of charge a death certificate in [Form 13] to the person entitled and intending to claim 4[funeral expenses].

95-D. Other evidence in lieu of a certificate.-The Corporation may accept any other evidence in lieu of a death certificate by Insurance Medical Officer if in its opinion, the circumstances of any particular case so justify.

95-E. Submission of claim for [funeral expenses].-(1) A claim to [funeral expenses] shall be submitted to the appropriate [Branch Office] by post or otherwise in [Form 22] by the claimant entitled under the Act and in case of a minor, by his guardian, and such claim shall be supported by documents proving,

(i) the death of the deceased person,

(ii) that the person claiming is the eldest surviving member of the family of the deceased insured person and incurred the expenditure necessary for the funeral of the deceased, or

(iii) in case the claimant is other than the eldest surviving member of the family

(a) that the deceased insured person did not have a family or that the deceased insured person was not living with his family at the time of his death;and

(b) that the claimant actually incurred the expenditure claimed on the funeral of the deceased insured person:

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

(2) The following may be accepted as proof for purposes of clauses (ii) and (iii) of sub-regulation (1) of this regulation

A declaration of the claimant duly countersigned by,

(i) an officer of the Revenue, judicial or Magisterial Departments of Government; or

(ii) a Municipal Commissioner; or

(iii) a Workmen's Compensation Commissioner; or

(iv) the Head of Gram Panchayat under the official seal of the panchayat;or

(v) the employer of the deceased insured person; or

(vi) any other evidence or declaration acceptable to the appropriate office in the circumstances of a particular case.

CHAPTER IV

Miscellaneous

Authority for determining benefits.-The authority for determining forpurposes of sub-section (2) of section 70 of the Act, the value of benefits other than cash payment shall be the Medical Commissioner of the Corporation.

96-A. Reimbursement of expenses incurred in respect of medicaltreatment.-Claims for reimbursement of expenses incurred in respect of medical treatment of insured person and (where such medical benefit is extended to his family) his family may be accepted in circumstances and subject to such conditions as the Corporation may by general or special order specify.

[96-B. Scale of medical benefit for rembursement.- An insured Person and his family (where such medical benefit is extended to his family) shall be entitled to receive reimbursement of medical treatment in emergent condition to the extent rates prescribed and published by State Government or the Corporation or for the Central Government Health (CGHS).]

[96-C. Referral for super speciality treatment to tie-up hospitals and expenditure to be incurred by Employees' State Insurance Corporation Directly.- Subject to the provisions of the Act and the Regulations, the Corporation or State Government may refer a beneficiary to any tie-up arranged medical facilities, where cost of such facility is borne directly by the Corporation and where the Fund permits; an insured person should have completed a minimum of six months of insurable employment from the date of registration and have contributed not less than seventy eight (78) days in the relevent contribution period including in which registration was made. However, where the facility has been extended to his family members, an insured person should have completed a minimum of one year of insurable employment and have contributed for not less than seventy eight (78) days in each of the two (2) contribution period and such benefit shall be available to an insured person or a beneficiary in the corresponding benefit period;

Provided further that an insured person with employment injury or Insured Woman with complications arising out of maternity or those in receipt of extended sickness benefit under the Act shall be eligible as per the relevent contributory conditions and in case of family of extended sickness beneficiaries, they shall also be eligible as long as the benefit period corresponding to contribution period covered in extended sickness by more than half of the contribution period.]

Discontinuance or reduction of benefits.-An employer may discontinue or reduce benefits payable to his employees under conditions of their service which are similar to the benefits conferred by the Act to the extent specified below, namely:

(a) from the date of the commencement of the first benefit period following the appointed day for his factory or establishment

(i) sick leave on half pay to the full extent;

(ii) such proportion of any combined general purposes and sick leave on half pay as may be assigned as sick leave but in any case not exceeding 50 per cent ofysuch combined leave;

(b) any maternity benefits granted to women employees to the extent to which such women employees may become entitled to the maternity benefit under the Act:

Provided that where an employee avails himself of any leave from theemployer for sickness, maternity or temporary disablement, the employer shall be entitled to deduct from the leave salary of the employee the amount of benefit to which he maybe entitled under the Act for the corresponding period.

Discharge, etc., of employee under certain conditions.-If the conditions of service of any employee so allow, an employer may discharge or reduce on due notice an employee

(i) who has been in receipt of disablement benefit for temporary disablement, after he has been in receipt of such benefit for a continuous period of six months or more;

(ii) who has been under medical treatment for sickness other than tuberculosis, leprosy, mental or malignant diseases or has, been absent from work as a result of illness duly certified in accordance with these regulations to arise out of the pregnancy or confinement rendering the employee unfit for work, after the employee has been under such treatment or has been absent from work for a continuous period of six months or more;

[(iii) who has been under medical treatment for any of the following diseases, duly certified in accordance with these regulations, after the employee has been under such treatment for a continuous period of 18 months or more, notwithstanding provisions of clauses (i) and (ii):

Diseases

[I. INFECTIOUS DISEASES

Tuberculosis
Leprosy
Chronic Empyema
Bronchiactesis

5.1 Interstitial Lung Disease

AIDS
NEOPLASMS
Malignant Diseases

III. ENDOCRINE NUTRITIONAL AND METABOLIC DISORDERS

Diabetes mellitus with proliferative retinopathy/diabetic foot/ nephropathy
DISORDERS OF NERVOUS SYSTEM
Monoplegia
HemiplegiaP
Paraplegia
Hemiparesis
Intracranial Space Occupying Lesion
Parkinson's disease
Spinal Cord Compression
Myaesthenia Gravis/Neuromuscular Dystr9phies
DISEASES OF EYE
Immature Cataract with vision 6/6 or less
Detachment of Retina
Glaucoma
DISEASES OF CARDIOVASCULAR SYSTEM
Coronary Artery Disease

(a) Unstable Angina

(b) Myocardial infraction with ejection less than 45%

Congestive Heart Failure:

Left

Right

Cardiac Vascular Diseases with failure /complications
Cardiomyopathies
Heart Disease with Surgical Intervention alongwith complications

VII. CHEST DISEASES

Chronic Obstructive Lung Disease (COPD) with congestive heart failure (Cor Pulmonale)

VIII. DISEASES OF THE DIGESTIVE SYSTEM

Cirrhosis of liver with ascities/chronic active hepatitis
ORTHOPAEDIC DISEASES
Dislocation of vertebra/prolapse of intervertebral disc
Non-union or delayed union of fracture
Post-Traumatic Surgical amputations of lower extremity
Compound fracture with chronic osteomyelitis
PSYCHOSES
Sub-groups under this are listed for clarification

(a) Schizophrenia

(b) Endogenous depression

(d) Dementia

OTHERS
More than 20% burns with infection/ complication
Chronic Renal Failure
Reynaud's disease/ Burger's disease.]
Suspension of sickness or temporary disablement benefit.-Sickness benefit or disablement benefit for temporary disablement may be suspended, if a person who is in receipt of such benefit fails to comply with any of the requirements of section 64 of the Act, and such suspension shall be for such number of days as may be decided by the authority authorised by the Director-General in this behalf.

[99-A. Sickness or temporary disablement benefit during strike.-Noperson shall be entitled to sickness benefit or disablement benefit for temporary disablement on any day on which he remains on strike except in the following circumstances:

(i) if a person is receiving medical treatment and attendance as an indoor patient in any Employees' State Insurance Hospital or a hospital recognised by the Employees' State Insurance Corporation for such treatment; or

(ii) if a person is entitled to receive extended sickness benefit for any of the diseases for which such benefit is admissible; or

(iii) if a person is in receipt of sickness benefit or disablement benefit for temporary disablement immediately preceding the date of commencement of notice of the strike given by the Employees' Union(s) to the management of the factory/ establishment;]

2 [(iv) if an insured person/insured woman has undergone operation on account of vasectomy/tubectomy, he/she shall be entitled to enhanced sickness benefit on any day on which he/she remains on leave during the period of strike or remains on leave, or on holiday for which he/she receives wages.]

Relaxation.-The Director-General may by special or general order relax any regulation under such circumstances and subject to such conditions, as he may deem fit.

101.[***]

Certain officers to have powers of inspection.-The Director General, the Insurance Commissioner, the [Additional Commissioner], a Regional Director, a [Joint Director, Deputy Director, Assistant Director] and a [ Branch Manager] shall have all the powers of a[Social Security Officer] specified in sub-section (2) of section 45 of the Act. In addition to the officers mentioned above, the Director General may, by a written order, confer upon any employee of the Corporation or any Government officer the powers of a[Social Security Officer] for such period or periods as he may think fit.

102-A. Inspection book.-(i) Every principal employer shall maintain a bound inspection book and shall be responsible for its production, on demand by [ a Social Security Officer] or any other officer of the Corporation duly authorised to exercise the powers of [ a Social Security Officer] irrespective of the fact whether the principal employer is present in the factory or establishment or not during the Inspection.

(ii) A note of all irregularities and illegalities discovered at the time of inspection indicating therein the action, if any, proposed to be taken against the principal employer together with the orders for their remedy or removal passed by [ a Social Security Officer] or any other officer of the Corporation duly authorised to exercise the powers of [ a Social Security Officer], shall be sent to the principal employer who shall enter the note and orders in the inspection book.

(iii) Every principal employer shall preserve the inspection bookmaintained under this regulation, after it is filled, for a period of 5 years from the date of the last entry therein.

Medical benefit during disablement.-A person who is in receipt of disablement benefit shall be entitled to medical benefit while he is in receipt of such benefit:

Provided that after the disablement has been declared as a permanent disablement, the person shall not be entitled to medical benefit, if he is not otherwise entitled to such benefit, except in respect of any medical treatment which may be rendered necessary on account of the employment injury from which the disablement resulted.

103-A. Medical benefit after contribution ceases to be payable.-(1) A person on becoming an insured person for the first time shall be entitled to medical benefit for a period of [three months]provided that where such a person continues for [three months] or more to be an employee of a factory or establishment to which the Act applies, he shall be entitled to medical benefit till the beginning of the corresponding benefit period.

[(2) The person in respect of whom contributions have been paid in a contribution period for not less than seventy-eight days in the said contribution period shall be entitled to medical benefit till the end of the corresponding benefit period:

Provided that in case of a person who becomes an employee within the meaning of the Act, for the first time, and for whom a shorter contribution period of less than 156 days is available, he shall be entitled to medical benefit till the end of the corresponding benefit period if the contributions in respect of him were payable for not less than half the number of days available for working in such contribution period:

Provided further that where a person suffering from any of the following diseases, before the commencement of the spell of sickness in which any such disease was diagnosed being in continuous service for a period of two years or more or where he did not have two years continuous service but by virtue of relaxation granted by the authority competent in this behalf, the insured person qualifies to claim extended sickness benefit, he shall be entitled-to medical benefit till the end of the relevant extended benefit period:

[I. INFECTIOUS DISEASES

Tuberculosis
Leprosy
Chronic Empyema
Bronchiactesis
Interstitial Lung Disease
AIDS
NEOPLASMS
Malignant Diseases
ENDOCRINE NUTRITIONAL AND METABOLIC DISORDERS
Diabetes mellitus with proliferative retinopathy/diabetic foot/ nephropathy
DISORDERS OF NERVOUS SYSTEM
Monoplegia
Hemiplegia
Paraplegia
Hemiparesis
Intracranial Space Occupying Lesion
Parkinson's disease
Spinal Cord Compression
Myaesthenia Gravis/Neuromuscular Dystrophies
DISEASES OF EYE
Immature Cataract with vision 6/6 or less
Detachment of Retina
Glaucoma
DISEASES OF CARDIOVASCULAR SYSTEM
Coronary Artery Disease

(a) Unstable Angina

(b) Myocardial infraction with ejection less than 45%

Congestive Heart Failure:

Left

Right

Cardiac Valvular Diseases with failure/ complications
Cardiomyopathies
Heart Disease with Surgical Intervention alongwith complications

VII. CHEST DISEASES

Chronic Obstructive Lung Disease (COPD) with congestive heart failure (Cor Pulmonale)

VIII. DISEASES OF THE DIGESTIVE SYSTEM

Cirrhosis of liver with ascities/chronic active hepatitis
ORTHOPAEDIC DISEASES
Dislocation of vertebra/ prolapse of intervertebral disc
Non-union or delayed union of fracture
Post-Traumatic Surgical amputations of lower extremity
Compound fracture with chronic osteomyelitis
PSYCHOSES
Sub-groups under this are listed for clarification

(a) Schizophrenia

(b) Endogenous depression

(d) Dementia

OTHERS
More than 20% burns with infection/ complication
Chronic Renal Failure
Reynaud's disease/ Burger's disease.]

[(3)] An insured person, whose title to medical benefit has ceased under this regulation shall again be entitled to medical benefit from the date of his re-employment as an employee under the Act by a factory or establishment to which the Act applies, if he produces a certificate from the employer in the form which may be specified by the Director-General for the purpose. Such an insured person shall, unless he is covered by sub-regulation (2), be entitled to medical benefit till the commencement of the benefit period corresponding to the contribution period in which he is re-employed.

[(4) An employer shall, on demand, issue the certificate referred to in sub-regulation (3) to an employee who has been employed by him after cessation of his previous insurable employment.]

[103-B. Medical benefit to insured person who ceases to be in insurable employment on account of permanent disablement.-(l) An insured person who ceases to be in insurable employment on account of permanent disablement caused due to employment injury shall continue to receive medical benefit for himself and his/her spouse till the date on which he would have vacated the employment on attaining the age of superannuation had he not sustained such permanent disablement, if he produces a certificate from the employer/a declaration in the form which may be specified by the Director-General for the purpose.

(2) Medical benefit to retired insured persons.-An insured person who has attained the age of superannuation[or retires under a Voluntary Retirement Scheme or takes premature retirement] shall be eligible to receive medical benefit for himself and his/her spouse, if he produces a certificate from the employer in the form which may be specified by the Director-General for the purpose.

(3) An employer shall, on demand, issue the certificate as referred to in sub-regulations (1) and (2) to an employee who had been employed by hirn.]

Production of document for medical benefit.-A person intending toclaim medical benefit, and who is otherwise entitled to such benefit, shall produce his identity Card or such other document as may have been issued in lieu thereof at the time of claiming such benefit if demanded by the Insurance Medical Officer and if he fails'to do so, medical benefit may be refused to him.
Further certificates.-Where any question arises as to the correctness of any certificate by virtue of which an insured person claims, or is entitled to, any benefit under the Acts, he shall, on being so required in writing or otherwise by the appropriate Office, submit himself, with a view to obtaining a further certificate, to medical examination by such medical authority as the Corporation may appoint in this behalf. If the further certificate specifies thedate on which the insured person is or will be fit to resume work, any certificate which is or has been issued by the Insurance Medical Officer for the same spell of incapacity shall, to the extent to which it relates to any period after and including the said date on the further certificate, be deemed not to have been issued in accordance with these regulations and such further certificate shall, notwithstanding anything contained in these regulations, be deemed to be a final certificate issued under regulations 58 and 60.

Notwithstanding anything contained in these regulations, such further certificate in so far as it relates to sickness or temporary disablement, may be issued at such interval and in respect of such periods as may be specified by such medical authority.

Change of circumstances to be notified.-Every person to whom any benefit is payable under the Act shall, as soon as may be practicable, notify the appropriate Office of any change of circumstance which he may be expected to know and which might affect the continuance of his right to receipt of such benefit.
Certificate in respect of a person claiming permanent disablement benefit.-Every person whose claim for any permanent disablement benefit has been admitted shall submit [in January] every year, a certificate in [Form 23] attested by such authority or persons and in such manner as may be specified by the Director General.

107-A. Declaration by and certificate in respect of a person claiming dependants' benefit.-Every person whose claim for any dependant's benefit has been admitted shall submit [In January] every year, a declaration and a certificate in [Form 24] attested by such authority or person and in such manner as may be specified by the Director-General.

107-B. Personal attendance of a person claiming permanent disablement benefit or dependants' benefit.-In the case of claimant for permanent disablement benefit or dependants' benefit, the appropriate [Branch Manager] may require personal attendance and due identification of any claimant, other than a person incapacitated by bodily illness or infirmity or a pardanashin lady at the appropriate [Branch Office] or at any other office of the Corporation provided that such appearance shall not be required more frequently than once in every six months.

[* * *]

[109. Submission of additional information by employer or insured person.-The employer or insured person, as the case may be, shall, on demand from the appropriate Office, submit information in such form as may be specified by the Director-General.]

[110. Procedure on implementation of Information Technology (IT) Roll Out.- Notwithstanding anything contained in these regulation, wherever, " on-line system" of functioning has been introduced, the registration of factory/ establishment and employees, filing of contributions, generation of challans, payment of contributions, submission and processing of claims for benefits and all other related procedures under the Act and the rules and regulations made thereunder, shall be submitted/ made on-line, with necessary digital signatures, wherever required, under these regulations, as may be specified by the Director General from time to time.]

FORM 01

*Employer's Code No.

Name of the Factory/Establishment

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

Complete postal address of the Factory/Establishment

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

(a) Telephone No., If any

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

(b) Fax No., if any

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

(d) name of Town/Revenue Village

...........................(Taluk/Tehsil)..........

(e) Police Station

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

(f) Revenue Demarcation/Hudbast No.

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

Location of Factory/Establishment

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

(a) State

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

(b) District

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

(a) Whether the building/premises of Factory/Establishment is owned or hired

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

(b) If hired or there is a change in the name of unit/ownership, please indicate-

(i) ESI Code No., if covered earlier

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

(ii) Date from which earlier Factory/Establishment closed down

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

(iii) Terms and conditions under which property acquired/taken on lease (enclose copy of agreement/relevant deed)

Details of Bank A/c:

(b)Name of Bank and Branch:

(a) Account No..........................

(i).......................................................

(b) Account No..........................

(ii).......................................................

(iii).......................................................

(a) Income Tax PAN/GIR No.

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

(b).Income Tax Ward/Circle/Area

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

Exact nature of work/business carried on

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

Date of commencement of Factory/Establishment

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

10.

(a) Whether registered under Factories/Shop and Establishment/Other Act (Please Specify)

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

(b).Factory Licence No./Trade Licence No./Catering Establishment Licence No./Shop Establishment Registration No./Licence No. under Cinematography Act, etc.

License No.

Date

Licensing Authority

(c)Please give whichever is applicable

No.

Date

Licensing Authority

(i) Commercial Tax No.

(i)

(ii) State Sales Tax No.

(ii)

(iii) Central Sales Tax No.

(iii)

(iv) Any other Tax No.

(iv)

(d).Maximum no. of persons that can be employed on any one day, as per licence

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

11.

(a) Whether power is used for manufacturing process as per section 2(K) of the Factories Act. If so, since when

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

(b).In case of factory whether Licence issued under section 2(m)(i) or 2(m)(ii) of the Factories Act, 1948

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

(c).Power connection No.

No.

Sanctioned power load

Issuing Authority

(a)Whether it is Public or Private Ltd. Company/Partnership/Proprietor-ship/Co-operative Society/Owner-ship (attach copy of Memorandum and Articles of Association/Partner-ship Deed/Resolution)

(b).Give name, present and permanent residential address of present Proprietor/Managing Directors, Director/Managing Partners, Partners/Secretary of the Co-operative Society

Name

(i)

(ii)

(iii)

(iv)

(v)

(vi)

(vii)

Designation

Address

13.

Address(es) of the Registered Office/Head Office/Branch Office/Sales Office/Administrative Office/other offices, if any,with no. of employees attached with each such office and person responsible for the office

Address as on date

No. of employees

Phone No./fax No.

Function

Person responsible for day-to-day functioning of the office

(Give details on a separate sheet, if required)

14.

(a) Whether any work/business carried out through contractor/immediate employer

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

(b).If yes, give nature of such work/business

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

15.

(a) EPF Code No.

No.

Issuing Authority

(If covered under EPF Act)

16.

Total number of employees employed for wages directly and through immediate employers on the date of application. (Whether manual/clerical/supervisor, connected with the administration or purchase of raw materials or distribution or sale of product/service, whether permanent or temporary).

As on date	Total No. of employees			No of employees drawing wages Rs.7,500 or less
	Male	Female	Total	Male	Female	Total
Employed directly by the Principal Employer
Through Immediate employer/contractor
Total

Total Wages paid in the preceding month

	Total wages	Wages paid to employees drawing wages Rs. 7,500 or less
To employees employed directly by the principal employer
To employees employed through Immediate employer/Contrator

18.

Give first date since when 10/20** or more coverable employees under ESI Act were employed for wages

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

Instructions

Note 1.-Please enclose photocopy of the following deeds/agreements/documents/ certificate:

(a) Registration Certificate/ Licence issued under Shops and Establishments Act or Factories Act.

(b) Latest Rent Bill of the premises you are occupying indicating the capacity in which, the premises is occupied, if applicable.

(d) Memorandum and Articles of Association/ Partnership Deed/Trust Deed.

(e) Zerox copy of certificate of commencement of production and/or Registration No. of CST/ST.

Note 2.-"Power" shall have the meaning assigned to it in the Factories Act, 1948 which is as under:

"Power" means electrical energy, or any other form of energy which is mechanically transmitted and is not generated by human or animal agency.

Note 3.-Manufacturing process as defined in section 2(k) in Factories Act is as under:

"Manufacturing process" means any process for

(i) making, altering, repairing, ornamenting, finishing, packing, oiling, washing, cleaning, breaking up, demolishing, or otherwise treating or adapting any article or substance with a view to its use, sale, transport, delivery or disposal;

(ii) pumping oil, water, sewage or any other substance;

(iii) generating, transforming or transmitting power;

(iv) composing types for printing, printing by letter press, lithography photogravure or other similar process or book binding;

(v) constructing, reconstructing, repairing, refitting, finishing or breaking up ships or vessels;

(vi) preserving or storing any articles in cold storage.

Note 4.-"Immediate employer" in relating to employees employed by or through him, means a person who has undertaken the, execution, on the premises of the factory or an establishment to which this Act applies or under the supervision of the principal employer or his agent, of the whole or any part of any work which is ordinarily part of the work of the factory or establishment of the principal employer or is preliminary to the work carried on in, or incidental to the purpose of, any such factory or establishment and includes a person by whom the services of an employee who has entered into a contract of service with him are temporarily lent or let on hire to the principal employer and includes a contractor.

Note 5.-"Principal employer" means

(a) In a factory, the owner or occupier of the factory and includes the managing agent of such owner or occupier, the legal representative of a deceased owner or occupier and where a person has been named as the manager of the factory under the Factories Act, 1948, the person so named;

(b) In any establishment under the control of any department of any Government, in India the authority appointed by such Government in this behalf or where no authority is so appointed, the head of the Department;

Note 6.-"Occupier" of a factory /establishment means the person who has ultimate control over the affairs of the factory/ establishment and when the said affairs are entrusted to a managing agent shall be the occupier of the factory/establishment.

Note 7.-"Employees" means any person employed for wages in or in connection with the work of a factory or an establishment to which this Act applies, and

(i) who is directly employed by the principal employer on any work of, or incidental or preliminary to or connected with the work of, the factory or establishment whether such work is done by the employee in the factory or establishment or elsewhere; or

(ii) who is employed by or through an immediate employer on the premises of the factory or establishment or under the supervision of the principal employer or his agent on work which is ordinarily part of the work of the factory or establishment or which is preliminary to be carried on in or incidental to the purpose of the factory or establishment; or

(iii) whose services are temporarily lent or let on hire to the principal employer by the person with whom the person whose services are so lent or let on hire has entered into a contact of service;

and includes any person employed for wages on any work connected with the administration of the factory or establishment or any part, department or branch thereofwith the purchase of raw materials for, or the distribution or sale of the products of, the factory or establishment; [or any person engaged as an apprentice, not being an apprentice engaged under the Apprentices Act, 1961 (52 of 1961), or under the standing orders of the establishment, but does not include]:

(a) any member of the Indian Naval, Military or Air Force; or

(b) any person so employed whose wages excluding remuneration for overtime work exceeds such wages as may be prescribed by the Central Government, a month:

Provided that an employee whose wages excluding remuneration for overtime workexceed such wages as may be prescribed by the Central Government, a month at any time after and not before the beginning of the contribution period, shall continue to be an employee until the end of that period.

Note 8.-"Wages" means all remuneration paid or payable in cash to an employee, if the terms of the contract of employment, express or implied, were fulfilled and includes any payment to an employee in respect of any period of authorised leave, lock-out, strike which is not illegal or lay-off and other additional remuneration, if any, paid at intervals not exceeding two months, but does not include:

(a) any contribution paid by the employer to any pension fund or provident fund, or under this Act;

(b) any travelling allowance or the value of any travelling concession;

(d) any gratuity payable on discharge.]

[FORM 01(A)

FORM OF ANNUAL INFORMATION ON FACTORY/ESTABLISHMENT COVERED UNDER ESI ACT

(Regulation 10-C)

1.	Name of the Factory/Establishment	:	................................................................
2.	Complete postal address of the Factory/Establishment	:	................................................................
3.	(a) Telephone No., if any	:	.................................................................
	(b) Fax No., if any	:	.................................................................
	(c) E-mail address, if any	:	.................................................................
	(d) Name of Town/Revenue Village	:	...............................(Taluk/Tehsil)..........
	(e) Police Station	:	..................................................................
	(f).Revenue Demarcation/Hudbast No.	:	..................................................................
4.	Location of Factory/Establishment
	(a) State	:	..................................................................
	(b) District	:	..................................................................
	(c) Municipality/Ward	:	..................................................................
5.	Details of Bank A/c:	:	(b) Name of Bank and Branch:
	(a) Account No.......................		(i).............................................................
	(b) Account No........................	:	(ii)............................................................
	(c) Account No............................	:	(iii)............................................................
6.	(a) Income Tax PAN/GIR No.	:	..................................................................
	(b) Income Tax Ward/Circle/Area	:	..................................................................
7.	(a) In case of factory whether licence issued under section 2(m)(i) or 2(m)(ii) of the Factories Act, 1948	:	..................................................................
	[***]	:
8.	(a) Whether it is Public or Private Ltd. Company/Partnership/Proprietorship/Co-operative Society/Ownership (Attach copy of Memorandum and Articles of Association/Partnership Deed/Resolution)
	(b) Give name, present and permanent residential address of present Proprietor/Managing Directors, Director/Managing Partners, Partners/Secretary of the Co-operative Society	:	Name (i) (ii) (iii) (iv) (v) (vi) (vii)			Designation			Address
9.	Address(es) of the Registered Office/Head Office/Branch Office/Sales Office/Administrative Office/Other offices, if any, with number of employees attached with each such office and person responsible for the office	:	Address as on date		No. of employees		Phone No./Fax No.	Function		Person responsible for day-to-day functioning of the office
			(Give details on a separate sheet, if required)
10	(a) Whether any work/business carried out through contractor/immediate employer	:	...................................................................................................
	(b) If yes, give nature of such work/business	:	.....................................................................................................
I hereby declare that the statement given above is correct to the best of my knowledge and belief. I also undertake to intimate changes, if any, promptly to the Regional Office/Sub-Regional Office, ESI Corporation as soon as such changes take place
Date................................................................................				Name and Signature..............................................
Place...............................................................................				Designation with seal.............................................
(Should be signed by principal employer under section 2(17) of ESI Act)

Table

FORM 1-A

(Regulation 15A)

FAMILY DECLARATION FORM

Name of the insured person ...............................................................................................

Insurance Number ...................................................................................................................

Serial No.

Name

Date of birth

Relationship with insured person

Whether residing with him/her or not

I hereby declare that the particulars above have been given by me and are true to the best of my knowledge and belief. I also undertake to intimate to the Corporation any changes in the membership of my family within 15 days of such changes having occured.

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

Date................

Signature or thumb-impression of the insured person

Counter-signed ...........................................

Date ..............................................................

Designation .................................................

Name, Address and, code no. of employer ...................................................................................

Note : According to section 2, clause (11) of the Employees' State Insurance Act, 1948,"family" means all or any of the following relatives of an insured person, namely, (i) aspouse; (ii) minor legitimate or adopted child dependent upon the IP; (iii) a child who iswholly dependent on the earnings of the IP and who is - (a) receiving education, till he orshe attains the age of 21 years, (b) an unmarried daughter; (iv) a child who is infirm by reasonof any physical or mental abnormality or injury and is wholly dependent on the earningsof the IP, so long as the infirmity continues; [(v) dependent parents, whose income from all sources does not exceed five thousand rupees a month; (vi) in case the insured person is unmarried and his or her parents are not alive, minor brothers and/or sisters wholly dependent upon the earnings of the insured person.]]

FORM 2

ADDITION/DELETION IN FAMILY DECLARATION FORM EMPLOYEE'S STATE INSURANCE CORPORATION

(Regulation 15B)

Name of the Insured Person__________________________

Insurance No.

I declare that the person/persons whose particulars are given below has/have now become/ceasedto be member(s) of my family*.

Sl.No.	Name	Date of birth	Reason(s) for change and date	Relationship with the insured person	Whether residing with him/her or not state		If no, where residing		Name of IMP/Disp.attached
					Yes	No	Distt.	State

I hereby declare that the particulars given above are true to the best of my knowledge and belief.

Necessary changes may kindly be made in my Declaration Form submitted earlier.

Passport size photographs of the members who are added to family is/are enclosed.

Place....................................

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

Date......................................

Signature/thumb impression of the employee

Name in Block letters_____________________

Particulars of the Employer:-		...............................
Name:..............................		Counter-signature of the employer
Address............................
.........................................
Code No............................
		.......................................
		Designation with Rubber Stamp

Note : "Family" means all or any of the following relatives of an Insured Person namely:-

(i) a spouse (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a child who iswholly dependant on the earnings of the I.P. and who is (a) receiving education, till he or she attains the age of 21 years (b) an unmarried daughter; (iv) a child who is infirm by reason of any physical ormental abnormality or injury and is wholly dependant on the earnings of the I.P. so long as theinfirmity continues; (v) dependant parents, whose income from all sources does not exceed five thousand rupees a month; (vi) in case the insured person 1S unmarried and his or her parents are not alive, minor brothers and/or sisters wholly dependent upon the earnings of the insured person] (Please see Section 2 clause 11 of the ESI Act 1948 for details)

*Please submit duly attested copy of the Birth/Death Certificate.]

FORM 3

(Regulation 14)

RETURN OF DECLARATION FORMS

Name and addres of the .......................................................................

Factory of Establishment......................................................................

Employer's Code Number........................................................................

I send herewith the Declaration Forms in respect of the employees mentioned below. I hereby declare that every person employed as an employee within the meaning of section 2(9) of the Employees' State Insurance Act, 1948, on...............................in this factory or establishment and in receipt of a remuneration not exceeding [Rs.15,000] per month has been included in this list (excepting only those in respect of whom declarations have been sent to the Corporation in the past). Place.........................................

Signature............................

Date..........................................

Designation........................

Serial No.

Name of the employee

Distinguishing No. with the employer, if any

Father's or Husband's name

Insurance No. allotted by the corporation (to be entered in the appropriate office)

(1)

(2)

(3)

(4)

(5)

Signature..........................

Designation........................

Enclosures:

Declaration Forms

Continuation sheets

FORM 4

(Regulations 17 and 95-A)

IDENTITY CARD

Insurance No.

Name....................Sex............................

Son of/daughter of/wife of..........................

Identification marks

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

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

Photograph of the insured person

Year of birth............................................

Address..................................................

Employment changes

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

Dispensary..............................................

Local Office.............................................

Date

Code No.

Date

Code No.

Prepared by............................................

Signature or thumb-impression of the employee

FROM 4-a

(Regulations 95-A)

FAMILY IDENTITY CARD

Insurance No.

Name of insured person...........................................................................

Sex..............................................................................

Son of/Daughter of/Wife of.......................................................

Address..........................................................................

Dispensary.......................................................................

Particulars of members of family
Serial No.	Name	Date of birth	Relationship with the insured person	Identification Marks
1.
2.
3.
4.
5.
6.

Prepared by

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

Signature of Ins pector of Authorised Officer

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

Signature or thumb-impression of the insured person]

[FORM 5

*Due Date for submission:-

12th May/11th November*

Name opf Branch Office............................

Employer's Code No...................

RETURN OF CONTRIBUTIONS

(Regulation 26)

EMPLOYEES'STATE INSURANCE CORPORATION

Name and address of the factory or establishment:........................................................

Particulars of the principal employer(S):...........................................................

(a) Name...............................................................

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

Contribution period:From...................................to..........................

I furnish below the details of the employer's and employee's share of contributions in respect of the undermentioned insured persons. I hereby declare that the return includes each and every employee, employed directly or through an immediate employer or in connection with the work of the factory/establishment of any work connected with the administration of the factory/establishment or purcahse of req materials, sale or distribution of finished products, etc., to whom the ESI Act, 1948 applies, in the contribution period to which this return relates and that the contributions in respect of employer's and employee's share have been correctly paid in accordance with the provisions of the Act and Regulations.

Employee's Share.........................................

Employer's Share.........................................

Total contribution.......................................

Sl.No.	Month	Date of Challan	Amount	Name of the Bank and Branch
1.
2.
3.
4.
5.
6.

Total amount paid:Rs....................................

Place..............................

Date...............................

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

Signature and Designation of the Employer

(With Rubber Stamp)

Important Instructions-Information to be given in "Remarks Column (No. 9)".

(i) If any L.P. is appointed for the first time and/or leaves during the contribution period indicate "A.......................................(date)" or "L.....................(date)".

(ii) Please indicate Insurance Nos. in ascending order.

(iii) Figures in Columns 4,5 and 6 shall be in respect of wage period ended during the contribution period.

(iv). Invariably strike totals of Columns 4, 5 and 6 of the Return.

(v) No overwriting shall be made. Any corrections, if made, should be signed by the employer.

(vi) Every page of this Return should bear full signature and rubber stamp of the employer.

(vii). Daily wages in Column 7 of the return shall be calculated by dividing figures in Column 5 by figures in Column 4 to two decimal places.

For *CP ending 31st March, due date is 12th May

For CP ending 30th September, due date is 11th November

EMPLOYEES'STATE INSURANCE CORPORATION

Employer's Name and Address............................................................................

Employer's Code No...................................Period From..................to............................

Sl.No.	Insurance Number	Name of insured person	No.of days for which wages paid	Total amount of wages paid (Rs.)	Employee's contribution deducted (Rs.)	Average daily wages (Rs.)	Whether still continues working	Remarks
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)







		Total

*Date of appointment and leaving the job may be given in remarks column.

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

Signature of the Employer

(FOR OFFICIAL USE)

Entitlement position marked
Total of Column 5 of Return checked and found correct/correct amount is indicated
Checked the amount of Employer's/Employee's contribution paid which is in order/observation memo enclosed.

Counter-signature.................................

U.D.C.

Head Clerk

Branch Officer

FORM 5-A

EMPLOYEES' STATE INSURANCE CORPORATION

(Regulation 31-Secong Proviso)

STATEMENT OF ADVANCE PAYMENT OF CONTRIBUTIONS MADE FOR THE CONTRIBUTION PERIOD ENDED................................

Total contribution amounting to Rs...........................comprising of..................Rs...................as employer's share and Rs...............................as employees' share paid as under:-

Sl.No	Details of advance payment	Amount	Details of actual contribution paid	Amount	Balance
(1)	(2)	(3)	(4)	(5)	(6)
		Rs. P.		Rs. P.	Rs. P.
1.	Opening Balance
2.	Challan dated.........	................	*April/October	...................	.....................
3.	Challan dated.........	................	*May/November	...................	.....................
4.	Challan dated.........	................	*June/December	...................	.....................
5.	Challan dated.........	................	*July/January	...................	.....................
6.	Challan dated.........	................	*August/February	...................	.....................
7.	Challan dated.........	................	*September/March	...................	.....................
	Total (i)...............	................	Total (ii) Total due for contribution period Total amount paid in advance Balance	...................	.....................
Total (ii) should not be less than total (i) at any time.
*Strike out whichever is not applicable.]
Place...........................................................				Signature............................
Date............................................................				Designation..........................

FORM 6

(Regulation 32)

EMPLOYEES' STATE INSURANCE CORPORATION

Sl.No	Insurance No.	Name of the insured person	*Name of dispensary to which attached	Occupation	Department and shift, if any	If appointed or left service during the contribution period, date of appointment/leaving service	No. of days for which wages paid/payable	Total amount of wages paid/payable	Employees' share of contribution
1	2	3	3-A	4	5	6	7	8	9

							Total
							Employer's share
							Grand Total
							Paid on

Month.......................................			Month..............................................			Month..............................................
No. of days for which wages paid/payable	Total amount of wages paid/ payable (Rs.)	Employees' share of contribution (Rs.)	No. of days for which wages paid/payable	Total amount of wages paid/payable	Employees' share of contribution (Rs.)	No. of days for which wages paid/payable	Total amount of wages paid/payable (Rs.)	Employees' share of contribution (Rs.)
10	11	12	13	14	15	16	17	18

Total			Total			Total
Employer's share			Employer's share			Employer's share
Grand Total			Grand Total			Grand Total
Paid on			Paid on			Paid on

Month..........................................			Month..........................................			Summary
No. of days for which wages paid/payable	Total amount of wages paid/payable (Rs.)	Employees' share of contribution (Rs.)	No of days for which wages paid/payable	Total amount of wages paid/payable (Rs.)	Employees' share of contribution (Rs.)	Total No. of days for which wages paid/payable in contribution period	Total amount of wages paid/payable in contribution period (Rs.)	Total Employees' share of contribution period (Rs.)	Daily wag (25-26) Rs.
19	20	21	22	23	24	25	26	27	28

Total			Total
Employer's share			Employer's share
Grand Total			Grand Total
Paid on			Paid on

Note.-The figures in Columns 7 to 24 shall be in respect of wage periods ending in a particular calendar month.]

FORM 7

(Confidential)

(Deposit this certificate within 3 days ith the appropriate Branch Office to avoid possible loss of benefit under regulation 64)

FIRST/INTERMEDIATE/FINAL CERTIFICATE

(Regulations 57, 58, 59 and 89-B)

EMPLOYEES' STATE INSURANCE CORPORATION

Book No.....................

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

Serial No....................

Stamp of dispensary

Signature or thumb-impression of L.P.

Date of First Certificate of spell of Sickness or

Employer's Code No......

Disablement.........................................................

Branch Office...............

Name...........................................................s/w/d......................................Insurance No

Any other remarks by the Medical Officer

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

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

(i)* You now need medical treatment, attendance and abstention from work on medical grounds by reason of (diagnosis).......................................................

(ii)* You have continued to need medical treatment, attendance and abstention from work on medical grounds up to and including this day by reason of (diagnosis)..........................................................

(iii)* In my opinion you will be fit to resume work tomorrow/on.............................................

Note.-The date of fitness must in no case be later than the third dya after of the examination in case of First Certificate.

Date....................................

Signature...........................

Insurance Medical Officer

(Rubber stamp)

Name in Block Letters.............................................

__________________

*Strike out whichever is not applicable.

Important:- 1. Any person who makes false statement or representation for the purpose of obtaining benefit whether for himself/some other person shall be punishable with imprisonment up to 6 months or fine up to Rs. 2,000 or both.

This form should be completed and submitted without delay to the appropriate Branch Office to escape penal deduction of benefit under regulation 64 read with regulation 99 of ESI (General) Regulations, 1950.
Insured person must sign, with date,the claim form to avoid delay and inconvenience.

FORM 8

(Confidential)

(Deposit this certificate within 3 dyas with the appropriate Branch Office to avoid possible loss of benefit under regulation 64)

SPECIAL INTERMEDIATE CERTIFICATE

(Regulations 61 and 89-B)

EMPLOYEES' STATE INSURANCE CORPORATION

Book No.....................

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

Serial No....................

Stamp of dispensary

Signature or thumb-impression of I.P.

Date of First Certificate of spell of Sickness or

Employer's Code No......

Disablement.........................................................

Branch Office...............

To...........................................................s/w/d......................................Insurance

Any other remarks by the Medical Officer

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

Certified that I have examined you...................................today and that in my opinion you have continued to need medical treatment and have remained incapable to work up to and including this day by reason of.............................................

I further certify that by judging your present condition it is found that your sickness is of such a character that it will be unnecessary to see you for the purpose of treatment more frequently than once in.....................weeks, and you will require medical treatment and will reamin incapable to work atlease up to the end of.....................weeks from this date.........................propose to issue certificates in this form at the interval stated above, so long as your condition does not require more frequent attendance. In my

Attestation by Medical Officer

Opinion you should now/need not be referred to a Medical Board to determine if you are permanently disabled.

Date...............

Signature....................

Insurance Medical Officer with rubber stamp

Name in block letters

FORM 9

CLAIM FOR SICKNESS/T.D.B./MATERNITY BENEFIT FOR SICKNESS

(Regulations 63 and 89-B)

EMPLOYEES'STATE INSURANCE CORPORATION

I........................................................Insurance No.........................s/w/d of............................................hereby claim Cash Benefit for period overleaf and State

(i)* That because of sickness/temporary disablement/sickness due to pregnancy/confinement/premature birth of child/miscarriage, I have not been at work since.........................

(ii)* I no longer claim to be sick/temporary disabled/sick due to pregnancy/confinement/premature birth to child/miscarriage from............... and I shall/did not take up any work for remuneration before that date.

(iii)*I have not been in receipt of any wages for the days of leave/holiday(s).

(iv)*I was not on strke during the period of certified abstention on account of sickness/temporary disablement, i.e., from ....................to...................for which the benefit is claimed.

I desire payment in *cash at Branch Office/By Money Order.

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

Signature of T.I. of Claimant

Name in block letters.......................

Address......................................

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

Notes:- 1. Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself/some other person shall be punishable with imprisonment up to 6 months or fine up to Rs. 2,000 or both.

This form should be completed and submitted without delay to the appropriate Branch Office.
A final certificate must be obtained before resuming work.

_____________________________

*Strike out if not applicable.]

[FORM 10

(CONFIDENTIAL)

ABSTENTION VERIFICATION IN RESPECT OF SICKNESS BENEFIT/

TEMPORARY DISABLEMENT BENEFIT/ MATERNITY BENEFIT

(Regulation 52-A(1) and (2))

EMPLOYEES' STATE INSURANCE CORPORATION

From:

The Manager

.............................. Branch Office,

E.S.I. Corporation,

M / s ............................

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

Subject: Verification of abstention from work in respect of Shri/Smt./Km ............................ Insurance No .............................Department..................................

Dear Sir(s)

The abovenamed employee of your factory has submitted a certificate of incapacity for the period from ...............................to............................and has declared that he/she has not worked on any day during the above period.

He/She has further declared that he/she has not received was as defined under section 2(22) of ESI Act, 1948 for any leave/holiday/weekly off/lay off and strike in respect of any day during uie above period and that he/she was not on strike on any day during the above period.

I shall be grateful if you confirm the exact position, in this regard, on the form, appended within 10 days of the receipt of this form.

Yours faithfully,

Manager

........................Branch Office

CONFIDENTIAL

REPLY TO BE FURNISHED BY THE EMPLOYER IN RESPECT OF FORM NO.10

Name of the insured Person/Insured Woman ................................................................

Insurance No ...................................................

Returned with the remarks that the employee in question has not worked on any day during the period from ..............................to..............................or* that he/she has worked on ..............................during the period from..............................to..............................

It is further confirmed that

(a) He/She remained on leave with wages for the period from .............. to................

(b) He/She remained on holidays with wages from .............. to..............

(d) He /She was on lay-off with wages from .............. to..............

(e) He /She was on strike from .............. to..............

In case, the IP/IW is paid any wages for any of the days falling during the abovementioned period subsequently, the same will be notified to you in due course.
The day proceeding the first day of absence was*/was not a holiday for the Insured Person/ Insured Woman.

Date ...........................

Signature.........................................................................

Name in block letters and Designation ......................

Code No ........................................................................

_____________________

*Strike out if not applicable.

FORM 11

ACCIDENT BOOK

(Regulation 66)

EMPLOYEES'STATE INSURANCE CORPORATION

Sl.No	Date of notice	Time of notice	Name and address of injured person	Sex	Age	Insurance No.	Shift, department and occupation of the employee	Details of Injury
								Cause	Nature		Date		Time		Place
1	2	3	4	5	6	7	8	9		10		11		12		13

What exactly was the injured person doing at the time of accident	Name, occupation, address and signature or the thumb-impression of the person (s) giving notice	Signature and designation of the person who makes the entry in the Accident Book	Name, address and occupation of two witnesses	Remarks, If any
14	15	16	17	18

FORM 12

ACCIDENT REPORT FROM EMPLOYER (Regulation 68)

EMPLOYEES' STATE INSURANCE CORPORATION

Name and Address of Factory/Establishment and Telephone No.

Nature of Industry or business

Employer's Code No.

4. Branch Office

Name and address of injured person

Sex and Age

7. Occupation

Insurance No.

9. Department

10.

Shift/Hrs. of work on the date of accident

11. Hour at which he started work on the day of accident

12.

Date and hour of accident

13. exact place of accident

14.

Nature and extent of injury (e.g., fatal, loss of finger, fracture of leg, scald, etc.)

15. Location of injury (right leg, left hand or left eye, etc.)

16.

Address of premises where accident happened

17. Date of death in case the injured person dies

18.In case the accident happened while meeting an emergency, please state:-

(i) Its nature-

(ii) Whether the injured person, at the time of the accident was employed for the purpose of his employer's trade or business in or about the premises at which the accident took place-

19.

Dispensary/IMP allotted to injured person

20. Dr. or Dispensary or Hospital from where injured person received or receiving treatment

21.

Name and Address of witness:-

Yes

22.

Whether wages in full or part are payable to him for the day of accident.

Yes

23.

Whether the injured person was an employee under section 2(9) of the Act on the day of accident.

Yes

24.

Whether contribution was payable by him for the day on which accident occurred.

Yes

25.

Cause of accident-

(a) State exactly what the injured person was doing at the time of accident, i.e., brief description of how the accident occurred...........................................................................

(b) Was the injured person, at the time of accident, acting in contravention of-

Yes

(1) The provision of any law applicable to him............

(2) any orders given by or on behalf of his employer.........................

(3) acting without instructions from his employer.........................

(c) In case reply to (b)(1),(2) or (3) is yes, state whether the act was done for the purpose of and in connection with the employer's trade or business

26.

In case the accident happened while travelling in the employer's transport, state whether the injured person was travelling:-

(1)

As a passenger to or from his place of work.

(2) with the express or implied permission of his employer.

(3).the transport is being operated by or on behalf of the employer of some other person by whom it is provide in pursuance of arrangement made with the employer, and

(4).The vehicle was being/not being operated in the ordinary course of public transport service.

Note.- Accident Report is required to be submitted to the appropriate Branch office as well as to Insurance Medical Officer/I.M.P. within 24 hours of the receipt of notice of injury. In case of fatal or serious accidents, it must be submitted Immediately to avoid legal penal action under section 85.

I certify that to the best of my knowledge and belief, the above particulars are correct in every respect.

Date of dispatch of report.....................................

Signature of the Employer....................

Name in block letters.............................

Designation..............................................

(with Stamp)

(FOR OFFICIAL USE)

Diary No. of accident register and date.....................

Signature of BM..............................................

FORM 13

(In Duplicate)*

DEATH CERTIFICATE

(For Dependant's Benefit or Funeral Expenses)

(Regulations 79 and 95-C)

EMPLOYEES'STATE INSURANCE CORPORATION

Book No................

Stamp of Dispensary

Sl.No........................

Name of the deceased insured person.......................................s/w/d of..........................Insurance No................................................

I certify that in my opinion the abovenamed deceased insured person died on the day of ...................20..............as a result of an injury/due to*................................I**had been attending him/her for providing medical benefit before his/her death and I attended him/her for the last time on the.............day of...........20..............

Signature.................................

Insurance Medical Officer/I.M.P.

Name in block letters and rubber stamp

Any other remarks by the Medical Officer

Dated........................

___________________________________

*Please indicate the name of the disease.

**May be suitably amended if the Insurance Medical Officer/I.M.P. has not attended the deceased person before his/her death.]

FORM 14

CLAIM FOR PERMANENT DISABLEMENT BENEFIT

EMPLOYEES'STATE INSURANCE CORPORATION

(Regulation 76-A)

I...............................s/w/d of..............................Insurance No.....................having been declared as permanently disabled by the Medical Borad/Medical Appeal Tribunal/Employees' Insurance Court, claim Permanent Disablement Benefit accordingly for the period from........................to.......................

The amount due may be paid to me by money order/in cash at Branch Office.

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

Signature of thumb-impression of the Claimant

Name in block letters.............................................

Address...............................................................

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

Date.........................

Important.-Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs.2,000 or with both.]

FORM 15

CLAIM FORM FOR DEPENDENT'S BENEFIT

(Regulation 80)

EMPLOYEES'STATE INSURANCE CORPORATION

Name of the deceased [Employee]............................................Insurance No....................................s/w/d/ of.........................................Date of Death..................................Last employed as...................................by............................................

I/We the following, being dependants of the abovenamed deceased insured person hereby claim and accordingly apply for dependant's benefit on account of his/her death:

Table I/We declare that the particulars given above are true to the best of my/our knowledge and belief.

i/We also declare that to the best of my/our knowledge and belief, there is no other dependant entitled to claim Dependant's benefit in r/o the death of the above noted deceased I.P., save and except those mentioned above.

Signatures*	1............................................................................
	2............................................................................
	3............................................................................
	4............................................................................

ATTESTATION**

Certified that the declarations, as made above, are true to the best of my knowledge and belief.

Name in block letters and Rubber stamp or seal of the attesting authority

Signature....................................

Designation................................

_____________________________

*All major dependants should sign individually and the guardian to sign in case of a minor dependent.

**This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Departments of Government, or(ii) a Municipal Commissioner, or (iii) a Workmen's Compensation Commissioner, or (iv) the Head of the Gram Panchayat under the official seal of the panchayat, or (v) M.L.A./M.P.(vi) Gazetted Officer, or (vii) a member of Local Committee/Regional Board of the ESI Corporation, or (viii) any other authority considered appropriate by the Branch Manager.

FORM 16

CLAIM FOR PERIODICAL PAYMENTS OF DEPENDANTS' BENEFIT

Regulation 83-A

EMPLOYEES'STATE INSURANCE CORPORATION

Name of the deceased insured person...............................Insurance No.................

I.................................,being the ...................of the above named deceased insured person and also being his/her dependant, do hereby claim Dependants' Benefit for the period from.......................to...................

The amount due may be paid to me	by money order
	in cash/by cheque at Branch Office

I also declare that-

*(i)I have not married*/re-married,so far

(Applicable only in case of a female dependant).

**(ii) I have not attained the age of 18 years

(Applicable in case of minor male/female dependant).

*(iii) I am still infirm

(Applicable donly in case of a legitimate/adopted* infirm son or a legitimate/adopted*unmarried infirm daughter who has attained 18 years of age. The claim to be accompanied, if required, by a certificate of specified authority).

Date.............................

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

**Signature or thumb-impression of the claimant

Present address................................

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

Name in block letters of Claimant/Guardian

**Signature or thumb-impression of the Guardian

For...........................................................

(name of the minor Dependant)

through......................................................

(name of the Guardian)

his/her.......................................................

(relationship with the Minor)

______________________________

*Please strike out whichever is not applicable.

**Applicable in the case of a claim by a major dependant.

***Applicable in the case of a claim for a minor dependant.]

[Please refer to rule 58 of the ESI (Central) Rules, 1950]

FORM 17

CERTIFICATE/NOTICE OF PREGNANCY MATERNITY BENEFIT

(Regulation 87)

EMPLOYEES' STATE INSURANCE CORPORATION

Signature or thumb-impression

of the Insured Woman

Employer's Code No.........................

Book No......................................................

Serial No......................................................

Insured Woman's Name.........................

Insurance No.............................................

Wife/Daughter of.....................................

Stamp of the dispensary

Certified that I have examined the abovementioned Insured Woman today and that in my opinion she is pregnant and her pregnancy appears to be......................weeks old.

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

Signature of midwife, if any

Date..............................

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

Signature or counter-signature

of the Insurance Medical Officer

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

Name in block letters

and Rubber Stamp

Any other remarks........................................................

I,............................................Insurance No..........................wife/daughter of.................................hereby give notice of pregnancy

Present address..............................................................................

Present/last employer............................................................................

Date................

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

Signature or thumb-impression

of the Insured Woman]

FORM 18

CERTIFICATE OF EXPECTED CONFINEMENT/CONFINEMENT/MISCARRIAGE/MATERNITY BENEFIT

(Regulations 88 and 89)

EMPLOYEES' STATE INSURANCE CORPORATION

Employer's Code No.........................

Book No......................................................

Serial No......................................................

Insured Woman's Name.........................

Insurance No.............................................

Wife/Daughter of.....................................

Stamp of the dispensary

I*Certified that I have examined that abovementioned Insured Woman today and that in my opinion she may expect to be confined on or about....................................

II*Certified that I attended the above mentioned Insured Woman in connection with her confinement/miscarriage at..................................................(address) and that she was there delivered of a child on the............................day of.......................

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

Signature of mid wife, if any

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

Signature or counter-signature

of the Insurance Medical Officer

Date........................................

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

Any other remarks........................

Name in block letters

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

and Rubber Stamp

______________________________

*Delete whichever is not applicable.]

FORM 19

CLAIM FOR MATERNITY BENFIT AND NOTICE OF WORKM

(Regulations 88, 89 and 91)

EMPLOYEES'STATE INSURANCE CORPORATION

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

Signature or thumb-impression

of the Insured Woman

Employer's Code No.........................

Book No......................................................

Serial No......................................................

Insured Woman's Name.........................

Insurance No.............................................

Wife/Daughter of.....................................

Stamp of the dispensary

I, the abovementioned Insured Woman hereby claim Maternity Benefit for expected confinement/confinement*/miscarriage with effect from ..................................

I, further declare that I have ceased*/shall cease to work for remuneration with effect from the aforesaid date.

*1, do hereby give notice that I have taken up/shall take up work for remuneration with effect from the ..........................I have drawn maternity benefit only upto..............................

Present employer** .............................................

Department, shift and occupation ....................

Present address ............................

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

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

Signature/ thumb-impression

of the Insured Woman

Name of the Branch Office

Date ...........................

__________________________________

*Please delete whichever is not applicable.

Important:-

No work for remuneration shall be taken up during the period for which Maternity Benefit is being claimed or is to be claimed.
Notice for resumption of work must be sent before any work is taken up.
Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for herself or for some other person, commits an offence punishable with imprisonment for a term which may-extend up to six months, or with a fine up to Rs. 2,000, or with both.]

FORM 20

CLAIM FOR MATERNITY BENEFIT AFTER THE DEATH OF AN INSURED

WOMAN LEAVING BEHIND THE CHILD

(Regulation 89-A)

EMPLOYEES' STATE INSURANCE CORPORATION

Claim arising from the death on .................................................of Ms........................................ wife/daughter of ........................................................................ having Insurance No................... and last employed by M/s .................................................................................................................

I ................................................................................................ *being related to the above named deceased Insured Person as her .......................................and being her nominee/being her legal representative (applicable if the I.W. dies leaving no nominee), hereby claim Maternity Benefit for the period from ......................... to.....................

I also declare that

**(i) the deceased Insured Woman died on .........................................leaving behind the child who is still alive; or

**(ii) the deceased Insured Woman died on ........................................leaving behind the child who also died on .............................

The amount due may be paid to me by Money Order/in cash at Branch Office.

I further declare that the particulars, as given hereinabove, are true to the best of my knowledge and belief.

Date ...........................

Signature/Thumb-impression of the claimant

Name in block letters and ....................................

Address of claimant .............................................

ATTESTATION

***Certified that the declarations, as made hereinabove, are true to the best of myknowledge and belief.

Name in block letters and Rubber stamp or seal of the attesting authority

Signature....................................

Designation................................

_______________________________

*Strike out this line if not applicable.

**Delete either (i) or (ii), as may not be applicable in the case.

***This certificate is to be given by (i) an officer of the Revenue, judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen's CompensationCommissioner; or (iv) the Head of the Gram Panchayat under the official seal of the Panchayat; or M.L.A./M.P.; (v) a Gazetted Officer of the Central/State Government/ Member of the Local Committee/ Regional Board; or (vi) any other authority considered as appropriate by the Branch Manager concerned.

Important.-1. This claim form, duly filled up, is required to be submitted to the appropriate Branch Office, together with a death certificate in Form 24-B, within 30 days of the death of the Insured Woman.

Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs. 2,000 or with both.

FORM 21

DEATH CERTIFICATE IN CASE OF CONFINEMENT FOR CLAIMING

MATERNITY BENEFIT

(Regulation 89-A)

EMPLOYEES' STATE INSURANCE CORPORATION

Stamp of the dispensary

Book No............

Name of the deceased Insured

Serial No...............

w/d of.....................

Insurance No..........

I certify that in my opinion

(i) the abovenamed deceased Insured Woman died on ..................................as a result of ........................................ during her confinement/*during a period of.................................., weeks (cause of death) immediately following her confinement, leaving behind the child.

*(ii) the said child also died on ..................................as a result of..............................................

Also certified that I had been attending her*/and also her said child for providing medical benefit before *her death/her said child's death and I attended her for the last time on ..................................and her said child for the last time..................................

Any other remarks

Date ...........................

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

Signature of Insurance Medical Officer/

Insurance Medical Practitioner

Rubber Stamp and name in block letters

Note.-(1) *Please delete whichever is not applicable.

(2) The language may be suitably amended if the Insurance Medical Officer/ Insurance Medical Practitioner had not attended the deceased person before her/her child's death.

FORM 22

FUNERAL EXPENSES CLAIM FORM

(Regulation 95-E)

EMPLOYEES' STATE INSURANCE CORPORATION

Claim arising from the death on ............................................of................................................... s/w/d of .....................................................................aged..........................................years, having Insurance No ............................and last employed as..................................................................by M/s .........................................................................Code No...............................................................

I ..................................................................................s/w/d of...................................................... aged ........................................years declare:

*(i) that I am the eldest surviving member of the family of the deceased Insured Person, whose particulars are furnished hereinabove, and that I actually incurred an expenditure of Rs ...................... (Rupees.......................................................only) necessary for the funeral of the said deceased personor

*(ii) that the deceased Insured Person, whose particulars are furnished thereinabove, did not have a family/was not living with his/her family at the time of his/her death and that I actually incurred an expenditure of Rs .........................(Rupees.................................only) on the funeral of the deceased Insured Person

Accordingly, I do hereby claim funeral expenses for the amount of Rs .................................. (Rupees ................................................. only)

Date ...........................

Name in block letters

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

Signature/Thumb-impression

of the claimant

ATTESTATION

**Certified that the declarations, as made hereinabove, are true to the best of myknowledge and belief.

Name in block letters and Rubber stamp or seal of the attesting authority

Signature....................................

Designation................................

*Delete either (i) or (ii), which may not be applicable in the case.

**This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (iv) the Head of the Gram Panchayat under the official seal of the Panchayat, or M.L.A./M.P.; or (v) a Gazetted Officer of the Central/State Government, Local Committee/ Regional Board; or (vi) any other authority considered as appropriate by the Branch Manager concerned.

Important.-Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs. 2,000 or with both.

Note.-In the case of a minor, the guardian should sign the claim form on behalf of the minor and then add the following below his/her signature:

____________________________________________

(Name of the Minor)

though____________________________________________through

(Name of Guardian)

(Relationship with the Minor)

FORM 23

(To be submitted alongwith claim of June and December)

LIFE CERTIFICATE FOR PERMANENT DISABLEMENT BENEFIT

(Regulation 107)

EMPLOYEES' STATE INSURANCE CORPORATION

*Certified that Shri/Smt ........................................................w/s/d of....................................... is alive this ................................day of......................20........

Signature..................................

Name in block letters of

Signing claimant

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

Designation with Rubber Stamp/Seal

of the Attesting Authority

Date ...........................

Important.-Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs. 2,000 or with both.

____________________________

*This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (iv) the Head of the Gram Panchayat under the official seal of the Panchayat; or (v) M.L.A./M.P.; or (vi) a Gazetted Officer of the Central/State Government; or (vii) a member of the Regional Board/Local Committee of the ESIC; or (viii) any other authority considered as appropriate by the Branch Manager concerned.]

FORM 24

(To be submitted alongwith claim of June and December)

DECLARATION AND CERTIFICATE FOR DEPENDANT'S BENEFIT

(Regulation 107-A)

EMPLOYEES' STATE INSURANCE CORPORATION

Name of the deceased Insured Person ................................... Insurance No.

I ...............................................................being the.......................................of the abovenamed deceased [Employee] and also being his dependant, do hereby solemnly declare:

*(i) that I have not married/re-married so far.

(To be given only by a female dependant)

*(ii) that I have not attained the age of eighteen years

(To be given only in respect of a minor male or female dependant) [other than legitimate or adopted son or daughter])

*(iii) that I have attained the age of [Twenty-Five years] but continue to be infirm

(To be given by a legitimate/ adopted infirm son or by a legitimate/ adopted infirm daughter. Certificate as specified, to be attached, if required).

[(iv) I have not attained the age of twenty-five years (Applicable in case of legitimate or adopted son).]

Present Address:..........................................................................

Date ...........................

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

Signature or thumb-impression

of the dependant

Name in block letters of signing claimant

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

Signature or thumb-impression of the

Guardian in case of a minor dependent

Name of the minor...................

Through............................

(Name of the Guardian)

his/her...................................

(Relationship with the Minor)

CERTIFICATE

**Certified that Shri/Smt/Kumari ..................................................................................w/s/dof ........................................................is alive this day, the ...................day of ....................20........ and that the declarations made above are true to the best of my knowledge and belief.

Date ...........................

Name in block letters and Rubber stamp or seal of the attesting authority

Signature....................................

Designation................................

__________________________

*Strike out whichever is not applicable.

**This certificate is to be given by (i) an officer of the Revenue, judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen's Compensation Commissioner; or (iv) the Head of the Gram Panchayat under the official seal of the Panchayat; or (v) M.L.A./M.P.; or (vi) a Gazetted Officer of the Central/State Government; or (vii) a member of the Regional Board/Local Committee of the ESIC; or (viii) any other authority considered appropriate by the Branch Manager concerned.

Important.-Any person who makes a false statement or misrepresentation for the purpose of obtaining benefit, whether for himself or some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs. 2,000 or with both.]

[***]

SCHEDULE-III

(Regulation 76-B)

COMMUTATION VALUES FOR PERMANENT DISABLEMENT BENEFIT

Age last birthday of insured person on the date on which the application for commutation is received in the appropriate office	The factory with which the daily rate of benefit is to be multiplied	Age last birthday of insured person on the date on which the application for commutation is received in the appropriate office	The factor with which the daily rate of benefit is to be multiplied
1	2	1	2
17 year and below	5690	49 years	4400
18 years	5670	50 years	4330
19 years	5660	51 years	4250
20 years	5640	52 years	4180
21 years	5620	53 years	4100
22 years	5600	54 years	4020
23 years	5580	55 years	3930
24 years	5560	56 years	3850
25 years	5540	57 years	3760
26 years	5510	58 years	3670
27 years	5480	59 years	3590
28 years	5460	60 years	3500
29 years	5420	61 years	3400
30 years	5390	62 years	3310
31 years	5360	63 years	3220
32 years	5320	64 years	3130
33 years	5280	65 years	3030
34 years	5240	66 years	2940
35 years	5200	67 years	2850
36 years	5160	68 years	2750
37 years	5110	69 years	2660
38 years	5070	70 years	2570
39 years	5020	71 years	2470
40 years	4970	72 years	2380
41 years	4910	73 years	2290
42 years	4860	74 years	2200
43 years	4800	75 years	2120
44 years	4740	76 years	2030
45 years	4670	77 years	1950
46 years	4610	78 years	1860
47 years	4540	79 years	1780
48 years	4470	80 years	1700]