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ESIC FORM 14 - PERMANENT DISABLEMENT BENEFITS
PDB is payable to an employee who suffers from permanent disablement as a result of EI (including Occupational Diseases) and which results in loss of earning capacity. Authority for examing the loss of capacity of the earning for injuries is the Medical Board and in the case of Occupational Diseases, Special Medical Board. The benefit is paid at the rate of 90% of wage in the form of monthly payment depending upon the extent of loss of earning capacity as certified by a Medical Board
Download FormESIC FORM 01 A - REGULATION SECTION 10 C
10 C is the submission of the annual details submitted by the establishments to the ESIC.It is the responsibility of the employer to whom the code allotted should furnish to the Sub Regional Office, Division Office by the 31st of January of every year. Employer will be responsible to all details mentioned in the Form 01A
Download FormESIC FROM 12A- Claim For Maternity Benefit For Sickness
The form is to be submitted by the employee to the employee to claim the benefit of the sickness during the pregnancy.
Download FormESIC FORM 13 - Claim for Sickness, Temporary Disablement or Maternity Benefit
Form to be submitted by the employee to the employer with all complete details required in the form to claim the sickness, temporary disablement, or maternity benefit.
Download FormESIC FORM 16- Claim for Periodically Payment Of Dependent benefits
The form is used by the dependent of the insured person to receive the benefits of periodically payment.
Download FormESIC FORM 21- Maternity Benefit-Certifcate of Expected Confinemet
Form is to be submitted by the employee to the employer mentioning the expected confinement period. Confinement-payable for a period of 12 weeks (84 days) on production of Form 21.
Download FormESIC FORM 24 - Declaration And Certificate For Dependents Benefits
The form is used to avail the dependent's benefits, the claimant can submit the declaration - cum -certificate at the ESIC office.
Download FormESIC FORM 23 - Life certificate For Permanent Disablement
The form is used to obtain the Life certificate to avail of Permanent Disability Benefit.The certificate is need to be attested by any of the following : - an officer of the Revenue, Judicial, or Magisterial Department - a Municipal Commissioner - a WorkmenÂ’s Compensation Commissioner - the Head of Gram Panchayat under the official seal of Panchayat - an M.L.A./M.P. - a Gazetted Officer of the Central/State Govt. - a member of the Regional Board/Local Committee of the ESIC - any other authority considered appropriate by the Branch Manager concerned
Download FormESIC FORM 22- FUNERAL EXPENSE CLAIM
ESIC has introduced Form 22 to claim the funeral expense of a deceased ESIC member. Family members /nominee needs to submit the filled/attested form at ESIC office within the 6 months of death to claim it. The form is effective from March 1, 2019 family member can claim from rs-10,000/- to 15,000/- as funeral expenses from ESIC Office
Download FormESIC FORM 20-Claim Maternity Benefit By The Nominee
In case of insured woman if death occurs after leaving the child behind nominee can claim the benefit .
Form to be submitted within the 30 days of death after attestation at the branch office with the death certificate of the member.
Download Form ESIC FORM 19- FOR MATERNITY BENEFIT/NOTICE OF WORK
ESIC claim form 19 has to be submitted to the employer by the insured pregnant woman in order to claim payment of maternity benefits.ESIC maternity claim form consists details like name of the insured woman,
ESIC IP number, the address of the pregnant woman, working department of the insured woman and present employer name.No work for remuneration shall be taken up during the period for which Maternity Benefit is being claimed or is to be claimed.
Download FormESIC FORM 15 - CLAIM DEPENDENT BENEFIT
Claim is submitted by the dependants of the insured person to accordingly apply for the dependant's benefit on account of member death.
Claim should be signed by all major dependents and by the major guardian in case of if the dependent is minor.
Download Form ESIC FORM 12 - ACCIDENT REPORT
Employer has to report the accident to the nearest ESI Branch Office in prescribe time limit.Submit report immediately within 24 hours of its occurrence as if the injury is serious i.e. it is likely to cause a death or permanent disablement or loss of a member
Now, it can be submitted online also as ESIC introduced the facility at ESI Employer Portal.
Download Form ESIC FORM 11- ACCIDENT FURNISH BOOK
Employers can get the Form-11 to furnish accident injury details.Every employer shall keep an accident book in which the any particulars of any accident causing personal injury to an insured person may be mentioned.
ESIC FORM 3- RETURN DECLARATION FORM
ESI Form 3 is a Return of Declaration form to be submitted during each month with the details of the Employees working in the purview of ESI during the given month.
Employer shall send a return of Declaration Forms in the given fomat, in
duplicate, within 10 days from the date on which the declaration Forms
are submitted.
Download Form ESIC FORM 2 - TO ADD/REMOVE THE BENEFICIARIES
Form 2 is used to add or remove the beneficiaries in the portal from availing the medical benefit.Family Members of IP who can avail benefit (his/her) :
- Spouse (his/her)
- Minor Dependent Son Up to 25 Years
- Dependant Unmarried Daughter Up to 25 Years
- Dependant Infirm Son by reason of any physical or mental abnormality or injury
- Dependant Infirm Unmarried Daughter
- Dependant Father
- Dependant Mother
- Minor Brother ( When there are no parents)
- Minor Sister (When there are no parents)
ESIC Form 9 - To claim Sickness/ Temporary Disablement Benefit/Maternity Benefit
It is submitted to claim the sickness, temporary disablement,
or maternity benefit, the employee needs to submit this form to the linked
branch office.
As per the ESI act, 1948Â if any person gives a false
statement or misrepresentation to obtain benefit whether for self/another
person shall be punishable with imprisonment of up to 6 months or with a fine
of up to Rs. 2,000/-, or both.
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