EMPLOYEES STATE INSURANCE ACT, 1948

Type &
Schedule Of Submission/
S.No Nature Of Description Of the Form Relevant Clause Submitting Authority Remarks
Maintenance
Document

to be filled in by the employee with his signature or thumb impression and

1 Form I Declaration Form Regulation 11 & 12
submit it to the employer

to be filled in by the employee and submitted back to the employer , who shall
2 Form I-A Family Declaration Form Regulation 15-A forward the same to the appropriate office within 10 days from the date of
submission by the employee

to be submitted by the insured person to the employer within 15 days of such

Changes in family declaration
3 Form I-B Regulation 15-B changes occurring and the employer in turn would forward the same to the
form
appropriate office within 10 days of receipt.

to be sent by the employer to the appropriate office within 10 days of receipt of

4 Form 3 Return of declaration forms Regulation 14
the filled up forms

to be issued by the appropriate office in respect of all insured employees, and

5 Form 4 Identity Card Regulation 17 send the same to the employer, who shall issue the same to the concerned
employee after obtaining the signature in the card

to be arranged by the appropriate office and necessary family particulars added

6 Form 4-A Family Identity Card Regulation 95-A
in Form 4

to be sent by the employer in quadruplicatealongwith receipt copies of challans

to the appropriate office within 42 days of termination of related contribution
7 Form 6 ESIC-Return of Contributions Regulation 26
period; within 21 days of permanent closure of the factory; within 7 days of the
date of receipt of requisition from the appropriate office

to be maintained by the employer in respect of every employee of his factory or

8 Form 7 Register Of Employees Regulation 32
establishment
 this medical certificate is to be issued by the insurance medical officer during
Regulation 57 & 89-
9 Form 8 First Certificate the first examination in respect of a spell of sickness or a spell of temporary
B
disablement

to be issued by the insurance meddical officer, when he feels that not later than
Regulation 58 & 89-
10 Form 9 Final Certificate 3 days of the date of examination(other than a first certificate) the insured
B
employee would be fit to resume duties

to be submitted by the insured person within 7 days (commencing from the date
Regulation 59 & 89-
11 Form 10 Intermediate Certificate of first certificate) in cases wherein the final certificate is not issued within 7
B
days of issue of first certificate

to be furnished by the insured person in cases wherein the insurance medical

Regulation 61 & 89-
12 Form 11 Special Intermediate Certificate officer feels that temporary disablement has continued for not less than 28 days
B
and such disablement is likely to continue for a longer period

to be submitted by the insured person desirous of claiming sickness or

Sickness or Temporary
13 Form 12 Regulation 63 temporary disablement benefit to the appropriate local office by post or
Disablement Benefit
otherwise alongwith appropriate medical certificates

to be submitted by every insured woman claiming maternity benefit in case of

14 Form 12-A Maternity Benefit for sickness Regulation 89-B sickness arising out of pregnancy, confinement, premature birth of child or
miscarriage to the local appropriate office by post or otherwise

Sickness or Temporary to be submitted by the insured person or insured woman desirous of claiming
Regulation 63 & 89-
15 Form 13 Disablement Benefit or Maternity sickness or temporary disablement benefit to the appropriate local office by post
B
Benefit for sickness or otherwise alongwith appropriate medical certificates

to be submitted by every insured woman claiming maternity benefit in case of

16 Form 13-A Maternity Benefit for sickness Regulation 89-B sickness arising out of pregnancy, confinement, premature birth of child or
miscarriage to the local appropriate office by post or otherwise

Sickness or Temporary to be submitted by the insured person or insured woman desirous of claiming
17 Form 14 Disablement Benefit or Maternity Regulation 63 sickness or temporary disablement benefit to the appropriate local office by post
Benefit for sickness or otherwise alongwith appropriate medical certificates

to be submitted by every insured woman claiming maternity benefit in case of

18 Form 14-A Maternity Benefit for sickness Regulation 89-B sickness arising out of pregnancy, confinement, premature birth of child or
miscarriage to the local appropriate office by post or otherwise
 To be maintained by the employer in which appropriate particulars of any
19 Form 15 Accident Book Regulation 66 accident causing personal injury to an insured person may be entered and
preserved every such book for a period of five years.

to be furnished by the employer to the nearest local office and to the nearest
20 Form 16 Accident Report from Employer Regulation 68
insurance medical officer immediately if the injury is serious

Dependant's benefit - Death Regulations 79 & 95- To be issued free of charge by the Insurance Medical Officer attending the
21 Form 17
Certificate C disabled person at the time of his death

To be submitted by the dependant or dependants concerned or by the legal

Dependant's benefit - Claim
22 Form 18 Regulation 80 representative of the insured member with all supporting documents to the
Form
appropriate local office by post or otherwise

To be submitted by the dependant whose claim for dependant's benefit is

Dependant's Benefit - Claim
23 Form 18-A Regulation 83-A admitted, to the local appropriate office except in the case of first and final
Form for periodical Payments
payments

Maternity Benefit - Notice of To be submitted by an insured woman before confinement to the local
24 Form 19 Regulation - 87
Pregnancy appropriate office

Maternity Benefit - Certificate of To be submitted by an insured woman before confinement to the local
25 Form 20 Regulation - 87
Pregnancy appropriate office

Maternity Benefit - Certificate of To be submitted by every insured woman claiming maternity benefit before
26 Form 21 Regulation - 88
Expected Confinement confinement not earlier than 15 days before the expected date of confinement

To be submitted by every insured woman to the local appropriate officestating

therein the date on which she ceases to work for remuneration and if the
27 Form 22 Maternity Benefit - Claim Form Regulation 88 & 89
insured woman is claiming maternity benefit for miscarriage the claim form
ought to be submitted within 30 days of the date of miscarriage.

Maternity Benefit - Certificate of To be submitted by every insured womanwothin 30 days of the date on which
28 Form 23 Regulation 88 & 89
Confinement or Miscarriage her confinement takes place to the local appropriate office
 To be furnished by an insured woman who has claimed maternity benefit, if she
Maternity Benefit - Notice Of
29 Form 24 Regulation 91 does work for remuneration on any day during the period for which maternity
Work
benefit would be payable to her.

Maternity Benefit after the death

To be submitted by the nominee or legal representative of the insured woman to
Form 24-A & of an insured woman leaving
30 Regulation 89-A the local appropriate office, a claim for maternity benefit within 30 days of the
24-B behind the child / Maternity
death of the insured woman, together with a death certificate in 24-B
Benefit- Death Certificate

Claim for Permanent To be submitted by an insured person declared as permanently disabled by a

31 Form 25 Regulation 76-A
Disablement Benefit Medical Board to the local appropriate office by post or otherwise

To be submitted by the claimant entitled, to the local appropriate office and in

32 Form 25-A Funeral Expenses Claim Form Regulation 95-E case of a minor, by his guardian and the form ought to be submitted with all
supporting documents

To be submitted by every person whose claim for permanent disablement has

Certificate for permanent
33 Form 26 Regulation 107 been admitted at six monthly intervals, a certificate attested by such authority as
disablement benefit
may be specified by the director general

To be submitted by every person whose claim for dependant's benefit has been
Declaration & Certificate for
34 Form 27 Regulation 107-A admitted at six monthly intervals , duly attested by such authority as may be
Dependant's Benefit
specified by the director general

To be furnished by every employer to the appropriate office, such particulars &

information in respect of abstention of an insured person from work for which
35 Form 28 Abstention Verification Regulation 52-A
sickness benefit or disablement benefit for temporary disablement have been
claimed or paid

To be furnished by every employer to the appropriate office, such particulars &

36 Form 28-A Abstention Verification Regulation 52-A information in respect of abstention of an insured woman from work for which
maternity benefit hass been claimed or paid