EMPLOYEES STATE INSURANCE (GENERAL) REGULATIONS, 1950

[RS/5/48, DATED 17-10-1950 In exercise of the powers conferred by section 97 of the Employees State Insurance Act, 194 !"4 of 194 #, the Employees State Insurance $orporation is pleased to ma%e the followin& re&ulations, the same ha'in& been pre'iously published as re(uired by sub) section !1# of the said section, namely*+ CHAPTER I S!"#$ $%$&' ()* '+$')$, 1. (1) These regulations may be called the Employees !tate Insurance ("eneral) Regulations# 1$%&. (') They e(tend to the )hole o* India including the +nion Territory o* Pondicherry e(cept the !tate o* ,ammu and -ashmir. D'-%)%$%")., '. In these regulations# unless the conte(t other)ise re.uires/ (a) 0Act1 means the Employees !tate Insurance Act# 1$23 (42 o* 1$23)5 (b) 0appointed day1 means )ith re*erence to any area# *actory or establishment# the day *rom )hich the )hole o* Chapters I6 and 6 o* the Act apply to such area# *actory or establishment# as the case may be5 (c) 0Appropriate 7**ice1# 0Appropriate 1[,ranch office 1 or 0Appropriate Regional 7**ice1# shall mean )ith re*erence to any action ta8en under these regulations# such o**ice o* the Corporation as may be speci*ied *or that purpose under a general or special order o* the Corporation5 (d) 0Central Rules1 means the rules made by the Central "o9ernment under section $% o* the Act5 (e) 1a:;;;< (f) ':;;;< (&) 0Employer1 means the principal employer as de*ined in the Act5 (h) 0Employer s Code =umber1 means the registration number allotted by the appropriate Regional 7**ice to a *actory or establishment *or the purposes o* the Act# the rules and these regulations5 (i) 0>actory or Establishment1 means a *actory or an establishment to )hich the Act applies5 (-) 0>orm1 means a *orm appended to these regulations5

4:(%)0Identity Card1 means a permanent identity card issued by the appropriate o**ice to an insured person *or identi*ication *or the purposes o* the Act# the Rules and these Regulations5< (%%) 0>amily Identity Card1 means a Card issued by the appropriate o**ice to an insured person *or identi*ication o* his *amily *or the purposes o* the Act# the rules and these regulations5 (l) 0Inspector1 means a person appointed as such by the Corporation under section 2% o* the Act5 (m) 0Instructions1 means instructions or orders issued by the Corporation or by such o**icer or o**icers o* the Corporation as may be authorised by the Corporation in this behal*5 (n) 0Insurance ?edical 7**icer1 means a medical practitioner appointed as such to pro9ide medical bene*it and to per*orm such other *unctions as may be assigned to him and shall be deemed to be a duly appointed medical practitioner *or the purposes o* Chapter 6 o* the Act5 (o) 0Insurance =umber1 means a number allotted by the appropriate o**ice to an employee *or the purposes o* the Act# the rules and these regulations5 (p) 04a[,ranch office 1 and 0Regional 7**ice1 shall mean# according to the conte(t# such subordinate o**ice o* the Corporation# set up at such place and )ith such @urisdiction and *unctions as the Corporation may# *rom time to time determine5 (() 04a[,ranch ?anager1 means a person appointed by the Corporation as such 2:or< the o**icerAinAcharge o* a Bocal 7**ice5 (r) 0!tate Rules1 means the rules made by a !tate "o9ernment under section $C o* the Act5 (s) 0Regional Director1 means a person appointed by the Corporation as such *or a speci*ied region5 (t) 0Registered ?id)i*e1 means a person )ho is registered as a mid)i*e under any la) in *orce in any !tate pro9iding *or registration o* nurses and mid)i9es5 (u) 0Rules1 means rules made by the Central or a !tate "o9ernment under the Act5 (') 0!peci*ied1 means speci*ied by instructions issued *rom time to time by the Corporation or any authorised o**icer5 (w) 0Eear1 means a calendar year e(cept )hen speci*ically stated other)ise5 (x) All other )ords and e(pressions ha9e the meanings respecti9ely assigned to them in the Act or the rules# as the case may be. T!' /())'# %) 0!%1! $!' C"#2"#($%") /(3 '+'#1%.' %$. 2"0'#., 4. (1) Fhere a regulation empo)ers the Corporation to speci*y# prescribe# pro9ide# decide or determine anything or to do any other act# such po)ers may be e(ercised by a resolution o* the Corporation or sub@ect to the pro9isions o* section 13 o* the Act by a resolution o* the !tanding CommitteeG

P#"4%*'* that the Corporation or the !tanding Committee may delegate any o* po)ers under these regulations to a subAcommittee or to such o**icers o* the Corporation as it may speci*y in that behal*G P#"4%*'* -5#$!'# that no po)er shall be delegated under this regulation )hich under the Act is re.uired to be e(ercised by the Corporation only. (') Any appointment to be made by the Corporation under these regulations# shall be made by the DirectorA"eneral or by such other o**icers as may be authorised in this behal* by the !tanding Committee. E+'#1%.' "- 2"0'#. 63 () "--%1', 4A. Fhere a po)er is to be e(ercised by the appropriate 7**ice or appropriate 4a[,ranch office or appropriate Regional 7**ice it shall be e(ercised by the o**icer *or the time being in charge thereo* or by such other o**icer as may be authorised *or the purpose under general or special orders o* the DirectorA"eneral. %:C")$#%65$%") ()* 6')'-%$ 2'#%"*., 2. Contribution periods and the corresponding bene*it periods shall be as under G $ontribution period $orrespondin& benefit period 1st April to 4&th !eptember 1st ,anuary o* the year *ollo)ing to 4&th ,une. 1st 7ctober to 41st ?arch o* the year 1st ,uly to 41st DecemberG *ollo)ing P#"4%*'* that in the case o* a person )ho becomes an employee )ithin the meaning o* the Act *or the *irst time# the *irst contribution period shall commence *rom the date o* such employment in the contribution period current on that day and the corresponding bene*it period *or him shall commence on the e(piry o* the period o* nine months *rom the date o* such employment.< %. C:; ; ;< M''$%)7. "- $!' C"#2"#($%"), $!' S$()*%)7 C"//%$$'' ()* $!' M'*%1(& 8')'-%$ C"5)1%&, C. The meetings o* the Corporation# the !tanding Committee and the ?edical Hene*it Council shall be held in accordance )ith the Central Rules at such time and place as may be *i(ed by the Chairman concerned. D'1%.%") 63 /(9"#%$3, I. E9ery matter coming up *or decision be*ore a meeting o* the Corporation# the !tanding Committee or the ?edical Hene*it Council shall be decided by a ma@ority o* persons present and 9oting at the time o* the meeting and in case o* e.uality o* 9otes the Chairman o* the meeting shall ha9e an additional casting 9ote.

M"*' "- '+'#1%.%)7 4"$', 3. The 9otes shall be ta8en by sho) o* hands and the names o* persons 9oting in *a9our and against any proposition shall be recorded only i* any member present re.uests the Chairman to do so. M($$'#. $" 6' 6#"57!$ 6'-"#' $!' C"#2"#($%"), $. In addition to the matters )hich are# under any speci*ic pro9ision o* the Act or the Central Rules# re.uired to be placed be*ore the Corporation# the *ollo)ing matters shall be re*erred to the Corporation *or its decision G/ (a) regulations under section $I and amendments thereto be*ore *inal publication5 (b) any measures proposed under section 1$ o* the Act5 (c) any proposal to e(tend medical bene*it to *amilies under subAsection (') o* section 2C5 (d) any dispute proposed to be re*erred to arbitration under subAsection (2) o* section %35 (e) any proposal to set up hospitals under section %$5 (f) any proposal to grant e(emption under section $15 (&) any proposal to enhance bene*its under section $$5 (h) any other matter )hich the corporation or its Chairman may direct the !tanding Committee or the DirectorA"eneral to place be*ore the Corporation. I:R'7%")(& 8"(#*., 1&. (1) A Regional Hoard may be set up *or each !tate or +nion Territory by the Chairman o* the Corporation and shall consist o* the *ollo)ing members# namelyG/ (a) a Chairman to be nominated by the Chairman o* the Corporation in consultation )ith the !tate "o9ernment or the Administration o* the +nion Territory5 (b) a 6iceAChairman to be nominated by the Chairman o* the Corporation in consultation )ith the !tate "o9ernment or the Administration o* the +nion Territory5 (c) one representati9e o* the !tate or the +nion Territory to be nominated by the !tate "o9ernment or the Administration o* the +nion Territory5 (d) (i) the Administrati9e ?edical 7**icer or any other 7**icer directly in charge o* the Employees !tate Insurance !cheme in the !tate or the +nion TerritoryJex officio. 3:(ii) the Regional Deputy ?edical Commissioner o* the CorporationJex officio.< (e) one representati9e each o* the employers and employees *rom the !tate or the +nion Territory to be nominated by the Chairman o* the Corporation in consultation )ith such organisations o* the employers and the employees as may be recommended *or the purpose by the !tate "o9ernment or the +nion Territory5

(f) members o* the Corporation other than the Chairman and the 6iceAChairman and o**icials# i* any# amongst those nominated by the Central "o9ernment under clause (c) o* section 2 o* the Act# residing in the !tate or the +nion TerritoryJex officio. $:(&) members o* the ?edical Hene*it Council nominated by the Central "o9ernment under clauses (e)# (f) and (&) o* section 1& o* the Act residing in the !tate or the +nion TerritoryJex officio G 1&:P#"4%*'* that )here the Chairman o* the Corporation so considers it to be e(pedient he may nominate such additional representati9es o* employers# and employees# not e(ceeding three *rom each side# )ith a 9ie) to pro9iding *or the ade.uate representation o* important organisations not included in the nominations o* the !tate "o9ernments# or the +nion Territory and to maintain the parity bet)een the number o* representati9e o* such employers and employeesG P#"4%*'* -5#$!'# that the Chairman o* the Corporation shall nominate such additional representati9es o* employers and employees not e(ceeding three *rom each side )here the number o* representati9es o* employers and employees including the ex officio members# i* less than three each.< 11:(') A Regional Hoard may# i* it considers it desirable# coAopt the 7**icer inAcharge o* a !ubARegional 7**ice set up )ithin its boundaries# andKor a member o* the medical pro*ession in the Region and the person(s) so coAopted shall continue to be member(s) during the pleasure o* the Regional Hoard.< (4) The Regional Director or 7**icerAinAcharge o* the Regional 7**ice shall be the member secretary o* the Hoard. (2)(i) !a9e as e(pressly pro9ided in this regulation# the term o* o**ice o* the members o* the Regional Hoard re*erred to in 1':clause (e) o* and the pro9iso to< subAregulation (1)# shall be 14:three years< commencing *rom the date on )hich their nomination is noti*ied# pro9ided that the members o* the Regional Hoard# shall# not)ithstanding the e(piry o* the said period# continue to hold o**ice until the nomination o* their successors is noti*ied. (ii) !a9e as e(pressly pro9ided in this regulation# the members o* the Regional Hoard re*erred to in 12:clause (c)< o* subAregulation (1) shall hold o**ice during the pleasure o* the !tate "o9ernment nominating them. (iii) A member o* the Regional Hoard re*erred to in 1%:clause (f)< or subAregulation (1) shall cease to hold o**ice )hen he ceases to be a member o* the Corporation or ceases to reside in that area. (i') Any member re*erred to in clause (i) o* this subAregulation nominated to *ill a casual 9acancy shall hold o**ice *or the remainder o* the term o* o**ice o* the member in )hose place he is nominated. (') An outgoing member shall be eligible *or renomination. (%) A member o* the Regional Hoard re*erred to in 1C:clause (e) o* and the pro9iso to< subAregulation (1) abo9e# may resign his o**ice by notice in )riting to the Chairman o* the Corporation# through the Chairman# Regional Hoard# and his seat shall *all 9acant on the acceptance o* the resignation. (C)(i) A member o* the Regional Hoard re*erred to in 1C:clause (e) o* and the pro9iso to< subAregulation (1) shall cease to be a member o* the Hoard i* he *ails to attend there

consecuti9e meetings thereo* pro9ided that his membership may be restored by the Chairman o* the Corporation on his being satis*ied as to the una9oidable nature o* the circumstances )hich led to his nonAattendance. (ii) Fhen any person nominated to represent an employer s or employee s organisation on the Regional Hoard has ceased to represent such organisation# the Chairman o* the Corporation# may# by noti*ication in the "aLette o* India# declare that such person shall cease to be a member thereo* )ith e**ect *rom such date as may be speci*ied therein. (I) The members o* the Regional Hoard shall recei9e such *ees and allo)ances as may be prescribed by the Central "o9ernment *or members o* the Corporation. (3) A member shall be dis.uali*ied *or being nominated or *or being a member o* the Regional Hoard G/ (i) i* he is declared to be o* unsound mind by a competent court 5 or (ii) i* he is an undischarged insol9ent5 or (iii) i* be*ore or a*ter the commencement o* the Regulations he has been con9icted o* an o**ence in9ol9ing moral turpitude. ($) The !ecretary shall# )ith the appro9al o* the Chairman# *i( the date# time and place o*# and also dra) up the Agenda *or# e9ery meeting. =otice o* not less than ten days *rom the date o* posting shall ordinarily be gi9en to e9ery member *or each meeting# pro9ided that i* it is necessary to con9ene an emergency meeting# a reasonable notice thereo* shall be gi9en to e9ery member. =o matter other than that included in the Agenda shall be considered e(cept )ith the permission o* the Chairman. (1&) =o business shall be transacted at any meeting unless there is a .uorum o* not less than one third o* the number o* the members on the Hoard# pro9ided that i* at any meeting# su**icient number o* members are not present to *orm a .uorum# the Chairman may ad@ourn the meeting to a date not later than se9en days *rom the date o* original meeting and it shall thereupon be la)*ul to dispose o* the business at such ad@ourned meeting irrespecti9e o* the number o* members present. (11) All matters shall be decided by a ma@ority o* persons present and 9oting and in case o* e.uality o* 9otes# the Chairman shall ha9e a casting 9ote or a second 9ote. (1') The Chairman or in his absence the 6iceAChairman o* the Regional Hoard shall preside at the meetings. In the e9ent o* the absence o* both the Chairman and the 6iceA Chairman the members present may elect one *rom amongst themsel9es to preside. (14) (i) The minutes o* each meeting sho)ing inter alia the names o* the members present thereat shall be *or)arded to all members o* the Regional Hoard as soon a*ter the meeting as possible and in any case not later than *i*teen days *rom the date o* the meeting. (ii) The records o* the minutes o* each meeting shall be signed by the Chairman a*ter con*irmation )ith such modi*ications as may be considered necessary at the meeting# at )hich the minutes are con*irmed. 1I:(12) A Regional Hoard shall per*orm the *ollo)ing *unctions in respect o* the Region *or )hich it is set upG

(a) !uch administrati9e andKor e(ecuti9e *unctions as may# *rom time to time be entrusted or delegated to it by a resolution# by the Corporation or the !tanding Committee. (b) To ma8e recommendations *rom time to time in regard to changes )hich may in its opinion be ad9isable in the Act# Rules and Regulations and *orms and procedure to be *ollo)ed in the running o* the !cheme. (c) To decide )ithin the broad *rame)or8 o* the general decisions and programme o* priorities o* the Corporation# the *ollo)ing matters# pro9ided that )here the speci*ic appro9al o* the Corporation or the appropriate "o9ernment is re.uired# such appro9al shall be ta8enG/ (i) e(tension o* the !cheme to other categories o* establishments in accordance )ith the order o* priorities laid do)n by the Corporation5 (ii) e(tension o* !cheme to ne) areas and e(tension o* medical care to *amilies5 (iii) adoption o* special measures to meet peculiar conditions in the area5 (i') impro9ement in bene*its5 (') pro9isions o* indoor medical treatment5 ('i) measures and arrangements *or the rehabilitation o* insured persons in the area# )ho are permanently disabled5 ('ii) securing compliance by employers )ith the 9arious pro9isions o* the Employees !tate Insurance Act# the Regulations and other Rules and instructions5 (d) To re9ie) *rom time to time the )or8ing o* the !cheme in the !tate both on the medical side as )ell as cash bene*it side and to ad9ise the Corporation and the !tate "o9ernment on measures to impro9e the )or8ing o* the !cheme both in regard to payment o* cash bene*its and administration o* medical bene*it and in particular to promote pre9enti9e health measures# sa*ety and personal hygiene and to re9ie) and chec8 la( certi*ication and other abuses o* the !cheme. (e) To loo8 into general grie9ances# complaints and di**iculties o* insured persons# employers# etc.# as it may consider necessary. (f) To ad9ise the Corporation on such matters as may be re*erred to it *or ad9ice by the !tanding Committee or the DirectorA"eneral. The Regional Hoard may set up suitable !ubACommittees *or carrying out any o* its *unctions and may see8 the assistance or ad9ice o* Bocal Committees )here necessary.< (1%)(i) I* in the opinion o* the Corporation# the Regional Hoard persistently ma8es de*ault in per*orming the duties imposed on it by or under this regulation or abuses its po)ers# the Corporation may by noti*ication in the "aLette o* India supersede the Regional Hoard. (ii) +pon the publication o* a noti*ication under clause ( i) abo9e superseding the Regional Hoard# all the members o* the Regional Hoard shall *rom the date o* such publication be deemed to ha9e 9acated their o**ices. (iii) Fhen the Regional Hoard has been superseded the Corporation may/ (a) immediately constitute a ne) Regional Hoard in accordance )ith this regulation5 or

(b) appoint such agency *or such period as it may thin8 *it to e(ercise the po)ers and per*orm the *unctions o* the Regional Hoard and such agency shall be competent to e(ercise all po)ers and per*orm all the *unctions o* the Regional Hoard. 13:L"1(& 1"//%$$''., 1&A. (1) A local committee may be set up *or such area as may be considered appropriate by the Regional Hoard and shall consist o* the *ollo)ing members# namelyG/ (a) a Chairman to be nominated by the Chairman# Regional Hoard# )ho shall be an o**icial o* the Corporation or o* the !tate in )hich the area is situated5 (b) an o**icial o* the !tate to the nominated by the !tate "o9ernment5 (c) the Administrati9e ?edical 7**icerAinAcharge o* the !cheme in the area concerned# ex officio, or any other medical o**icer nominated by him5 (d) such number# to being less than t)o nor more than *our# o* representati9es o* employers in the area as may be considered appropriate by the Chairman# Regional Hoard# to be nominated by him# in consultation )ith such employers organisations as may be recommended *or the purpose by the !tate "o9ernment5 (e) an e.ual number o* representati9es o* employees in the area to be nominated by the Chairman# Regional Hoard# in consultation )ith such organisations o* employees as may be recommended *or the purpose by the !tate "o9ernment5 (f) an o**icial o* the Corporation to be nominated by the DirectorA"eneral# )ho shall also act as !ecretary to the CommitteeG P#"4%*'* that )here the Chairman# Regional Hoard# so considers it to be e(pedient# he may nominate such additional representati9es o* employers and employees# not e(ceeding t)o *rom each side# )ith a 9ie) to pro9iding *or the ade.uate representation o* important organisations not included in the nominations o* the !tate "o9ernment and to maintaining the parity bet)een the number o* representati9es o* such employers and employeesG P#"4%*'* -5#$!'# that in any area in )hich medical care is pro9ided through a panel system# a local committee may coAopt a member representing the local Insurance ?edical Practitioners. (')(i) The term o* o**ice o* the members o* a local committee nominated under clauses (d) and (e) o* subAregulation (1) shall be 1$:three years<# commencing *rom the date on )hich their nomination is noti*ied# pro9ided that such members# shall# not)ithstanding the e(piry o* the said period# continue to hold o**ice until the nomination o* their successor is noti*ied. (ii) The members o* a local committee nominated under clauses (b)# (c) and (f) o* subA regulation (1) shall hold o**ice during the pleasure o* the authority nominating them. (4) A member o* a local committee may resign his o**ice by notice in )riting to the Chairman# Regional Hoard# and his seat shall *all 9acant on the acceptance o* the resignation. (2)(i) A member o* a local committee shall cease to be a member o* the Committee i* he *ails to attend three consecuti9e meetings thereo* pro9ided that this membership may be

restored by the Chairman# Regional Hoard# on being satis*ied as to the una9oidable nature o* the circumstances )hich led to his nonAattendance. (ii) Fhere in the opinion o* the !tate "o9ernment any person nominated to represent employers or employees on a local committee has ceased to represent such employers or employees# the Chairman# Regional Hoard# may declare that such person shall cease to be a member thereo* )ith e**ect *rom such date as may be speci*ied by him. (%) The members o* the committee shall recei9e such *ees and allo)ances as may be speci*ied by the Central "o9ernment. (C) The !ecretary# shall# in consultation )ith the Chairman# *i( the date# time and place o*# and also dra) up the Agenda *or e9ery meeting. =otice o* not less than se9en days shall ordinarily be gi9en to e9ery member *or such meeting. =o matter other than that included in the Agenda shall be considered e(cept )ith the permission o* the Chairman. (I) =o business shall be transacted at any meeting o* a committee unless there is a .uorum o* not less than oneAthird o* the number o* the members o* the committee. (3) All matters at a meeting o* a local committee shall be decided by a ma@ority o* persons present at the meeting and 9oting# and in case o* e.uality o* 9otes# the Chairman shall ha9e a casting 9ote or a second 9ote. ($) A local committee shall per*orm the *ollo)ing *unctions in respect o* the area *or )hich it is set up# namelyG/ (a) to discuss local problems in regard to the Employees !tate Insurance !cheme so as to secure its e**icient )or8ing )ith the *ull coAoperation o* all parties concerned and to ma8e recommendations5 (b) to re*er such complaints as it may consider necessary to the Regional Director concerned# or in the case o* complaints concerning medical bene*it# to the !tate "o9ernment or such authority as that "o9ernment may nominate *or the purpose5 and (c) to ad9ise the Corporation or the Regional Hoard concerned on such matters as may be re*erred to it *or ad9ice.< CHAPTER II COLLECTION O: CONTRI8UTIONS, ETC, R'7%.$#($%") "- :(1$"#%'. "# E.$(6&%.!/')$., 1&H. (a) The employer in respect o* a *actory or an establishment to )hich the Act applies *or the *irst time and to )hich an Employer s Code =umber is not yet allotted# and the employer in respect o* a *actory or an establishment to )hich the Act pre9iously applied but has ceased to apply *or the time being# shall *urnish to the appropriate Regional 7**ice not later than 1% days a*ter the Act becomes applicable# as the case may be# to the *actory or establishment# a declaration o* registration in )riting in >orm &11$a[and /orm 01)A (hereina*ter re*erred to as Employer s Registration >orm). (b) The employer shall be responsible *or the correctness o* all the particulars and in*ormation re.uired *or and *urnished on the Employer s Registration >orm.

(c) The appropriate Regional 7**ice may direct the employer )ho *ails to comply )ith the re.uirements o* paragraph (a) o* this regulation )ithin the time stated therein# to *urnish to that o**ice Employer s Registration >orm duly completed )ithin such *urther time as may be speci*ied and such employer shall# thereupon# comply )ith the instructions# issued by that o**ice in this behal*. 1$a[(cc) 1he employer in respect of a factory or establishment to which a code number has been issued by the $orporation based on information collected or decision ta%en re&ardin& applicability of the Act to such factory or establishment, shall, within fifteen days or receipt of information of allotment of code number, furnish a declaration in /orm)012 (d) +pon receipt o* the completed Employer s Registration >orm# the appropriate Regional 7**ice shall# i* satis*ied that the *actory or the establishment is one to )hich the Act applies# allot to it an Employer s Code =umber (unless the *actory or the establishment has already been allotted an Employer s Code =umber) and shall in*orm the employer o* that number. (e) The employer shall enter the Employer s Code =umber on all documents prepared or completed by him in connection )ith the Act# the rules and these regulations and in all correspondence )ith the appropriate o**ice. 1$a[S56/%..%") "- ())5(& %)-"#/($%") 63 -(1$"#%'./'.$(6&%.!/')$., 10$2 1he employer in respect of a factory or establishment to which this Act applies and to whom a code number has already been allotted, shall furnish to the appropriate 3e&ional 4ffice or Sub)3e&ional 4ffice or 5i'isional 4ffice, by "1st of 6anuary e'ery year, a return in /orm 01)A2 1he employer shall be responsible for correctness of all particulars and information furnished in /orm 01)A2 D'1&(#($%") 63 2'#."). %) '/2&"3/')$ ") (22"%)$'* *(3, 11. The employer in respect o* a *actory or an establishment shall re.uire e9ery employee in such *actory or establishment to *urnish and such employee shall on demand *urnish to him either be*ore or on the appointed day correct particulars re.uired *or the purpose o* >orm 1 (hereina*ter re*erred to as the Declaration >orm). !uch employer shall enter the particulars in the Declaration >orm including the temporary Identi*ication Certi*icate# and obtain the signature or the thumbAimpression o* such employee and also complete the *orm as indicated thereon. D'1&(#($%") 63 2'#."). ')7(7'* (-$'# $!' (22"%)$'* *(3, 1'. (1) The employer in respect o* a *actory or an establishment shall# be*ore ta8ing any person into employment in such *actory or establishment a*ter the appointed day# re.uire such person (unless he can produce an Identity Card or other document in lieu thereo* issued to him under these regulations to *urnish and such person shall on demand *urnish to him correct particulars re.uired *or the Declaration >orm including the Temporary Identi*ication Certi*icate. !uch employer shall enter the particulars in the Declaration

>orm including the Temporary Identi*ication Certi*icate and obtain the signature or the thumb impression o* such person and also complete the *orm as indicated thereon. (') Fhere an Identity Card is produced under such subAregulation (1)# the employer shall ma8e rele9ant entries thereon. 14. '&:; ; ;< D'1&(#($%") :"#/ $" 6' .')$ $" '1[(22#"2#%($' "--%1', 12. The employer shall send to the appropriate '':; ; ;< o**ice by registered post or messenger# all Declaration >orms )ithout detaching the temporary identi*ication certi*icate prepared under these regulations together )ith a return in duplicate in >orm 4 )ithin 1& days o* the date on )hich the particulars *or the Declaration >orms )ere *urnished. A&&"$/')$ "- I).5#()1' N5/6'#, 1%. 7n receipt o* the return re.uired under regulation 12# the '1:appropriate< 7**ice shall promptly allot an Insurance =umber to each person in respect o* )hom the Declaration >orm has been recei9ed unless it *inds that the person had already been allotted an Insurance =umber. The temporary Identi*ication Certi*icate )ith Insurance =umbers mar8ed thereon shall be detached and returned to the employer along )ith one copy o* >orm 4. The employer shall deli9er the Temporary Identi*ication Certi*icate to the employee to )hom it relates a*ter obtaining his signature or thumbAimpression thereon e(cept in the case o* an employee to )hom a certi*icate o* employment has been issued under Regulation 1IA. The Insurance =umber allotted by the '1:appropriate< o**ice to an employee and indicated in the copy o* >orm 4 returned to the employer# shall be entered by the employer on the ''a:register o* employees (>orm I) and return o* contributions<. '4:R'7%.$#($%") "- -(/%&%'., 1%A. 7n the issue o* a noti*ication under regulation $%A# speci*ying the date *rom )hich the *amily o* an insured person shall also be entitled to medical bene*it under the Act# e9ery insured person )ho has not *urnished the particulars o* his *amily at the time o* his registration under the Act# shall *urnish to the employer correct particulars in respect o* his *amily in >orm 1A. the employer shall enter the particulars in the *orm and obtain the signature or the thumb impression o* such person and complete the *orm as indicated thereon and send it to the appropriate o**ice on or be*ore the !aturday *ollo)ing the end o* the )ee8 in )hich the particulars )ere *urnished. C!()7'. %) -(/%&3, 1%H. An insured person shall intimate all changes in the membership o* the *amily as de*ined under the Act# to the employer )ithin 1% days o* such change ha9ing occurred and the employer shall enter such particulars in >orm '4a[7 and shall *or)ard it to the

appropriate o**ice on or be*ore the !aturday *ollo)ing the end o* the )ee8 in )hich the particular o* the changes )ere *urnished.< T!' C"#2"#($%") $" #'1'%4' (..%.$()1' -#"/ '/2&"3'#., 1C. An employer shall render all necessary assistance )hich the Corporation may re.uire in connection )ith the registration o* his *actory or establishment and the registration o* his employees and specially *or photographing such employees and a**i(ing the photographs to the identity cards. '2:I*')$%$3 1(#*., 1I. The appropriate o**ice shall arrange to ha9e an identity card prepared in >orm 2 *or each person in respect o* )hom an insurance number is allotted and shall include in such card the particulars o* the *amily entitled to medical bene*it under regulation $%A and shall send all such identity cards to the employer. !uch employer shall i* and )hen the employee has been in his ser9ice *or '%:4 months<# obtain the signature or thumb impression o* the employee on the identity card and shall a*ter ma8ing rele9ant entries thereon# deli9er the identity card to him. The employer shall obtain a receipt *rom the employee *or the identity card. The identity card in respect o* an employee )ho has le*t employment be*ore '%:4 months< shall not be gi9en to him# but shall be returned to the appropriate o**ice as soon as possible. I..5' "- ( C'#$%-%1($' "- E/2&"3/')$, 1IA. I* an insured person happens to need medical care be*ore the Temporary Identi*ication Certi*icate is issued to him# the employer shall issue a certi*icate o* employment in such *orm as may be speci*ied by the DirectorA"eneral to such person on demand. !uch certi*ication shall also be issued on demand# i* an insured person loses his Temporary Identi*ication Certi*icate be*ore the receipt o* the identity card. I..5' "- P'#/()')$ A11'2$()1' C(#*, 1IH. In areas )here the DirectorA"eneral considers it appropriate# the 'C:appropriate< 7**ice shall also supply a permanent Acceptance Card *or each employee in such *orm as the DirectorA"eneral may speci*y along )ith the identity card and this shall also be deli9ered to the employee. Permanent Acceptance Card *or the employee )ho has le*t employment be*ore 'I:4 months< shall not be gi9en to him but returned to the appropriate o**ice along )ith the identity card as soon as possible. L".. "- I*')$%$3 C(#* 13. In case o* loss# de*acement or destruction o* an Identity Card# the insured person shall report the matter to the appropriate 'Ia[,ranch office # and the Corporation may issue a duplicate copy o* the Identity Card sub@ect to such conditions and payment o* such *ees as may be determined by the DirectorA"eneral.

1$. '3:;;;< '&. '3:;;;< '1. '3:;;;< ''. '3a:;;;< '4. '3:;;;< L".. "- C")$#%65$%") C(#*, '2. '$:;;;< R'-5)* -"# 1")$#%65$%") .$(/2., '%. 4&:;;;< 41:R'$5#) "- 1")$#%65$%"). $" 6' .')$ $" (22#"2#%($' "--%1', 'C. (1) E9ery employer shall send a return o* contributions in .uadruplicate in >orm 41a[8 along )ith receipted copies o* challans *or the amounts deposited in the Han8# to the appropriate o**ice by registered post or messenger# in respect o* all employees *or )hom contributions )ere payable in a contribution period# so as to reach that o**ice as/ 4':(a) )ithin 2' days o* the termination o* contribution period to )hich it relates<5 44:(b) )ithin '1 days o* the date o* permanent closure o* the *actory or establishment# as the case may be<5 (c) )ithin I days o* the date o* receipt o* re.uisition in that behal* *rom the appropriate o**ice. (') >or the purposes o* section II o* the Act# the due date by )hich the e9idence o* contributions ha9ing been paid must reach the Corporation shall be the last o* the days respecti9ely speci*ied in clauses (a)# (b) M (c) o* subAregulation (1).< 42:I..5' "- 1'#$%-%1($' "- 1")$#%65$%")., 'I. An employer shall# on demand *rom the appropriate o**ice# issue certi*icate o* contributions paid or payable in respect o* an insured person in such *orm as may be speci*ied by the DirectorA"eneral.< '3. 4%:;;;< 4C:P(3/')$ "- 1")$#%65$%"), '$. Contribution payable under the Act shall# e(cept )hen other)ise pro9ided# be paid into a Han8 duly authorised by the Corporation.< 4&. 4I:;;;<

4C:T%/' -"# 2(3/')$ "- 1")$#%65$%"), 41. An employer )ho is liable to pay contributions in respect o* any employee shall pay those contributions )ithin '1 days o* the last day o* the calendar month in )hich the contributions *all due G< 43:P#"4%*'* that )here a *actoryKestablishment is permanently closed# the employer shall pay contribution on the last day o* its closure G< 4$:P#"4%*'* that an employer may opt# in such manner as may be prescribed# by the DirectorA"eneral *or payment o* amount in ad9ance to)ards contribution to be ad@usted against contributions payable by him (including employees contribution) *or a )age period so that the balance o* ad9ance amount continues to be more than the contributions due and payable at the end o* the concerned )age period. !uch an employer shall *urnish in the prescribed pro*orma (>orm 4$a[8 A)# a si( monthly statement o* contributions payable and paid in ad9ance )ith the balance le*t at the end o* each month along )ith return o* contributions to the appropriate regional o**ice o* the Corporation.< 2&:I)$'#'.$ ") 1")$#%65$%") *5', 65$ )"$ 2(%* %) $%/', 41A. An employer )ho *ails to pay contribution )ithin the periods speci*ied in regulation 41# shall be liable to pay 21:simple interest at the rate o* 1% per cent per annum< in respect o* each day o* de*ault or delay in payment o* contribution.< 2':R'1"4'#3 "- %)$'#'.$, 41H. Any interest payable under regulation 41A may be reco9ered as an arrear o* land re9enue or under section 2%C to section 2%AI o* the Act.< 24[D(/(7'. "# 1")$#%65$%"). "# ()3 "$!'# (/"5)$ *5', 65$ )"$ 2(%* %) $%/', 41C. An employer )ho *ails to pay contributions )ithin the periods speci*ied under regulation 41# or any other amount payable under the Act# shall be liable to pay damages as underG 9eriod of delay (i ) (ii) +p to ' months ' months and abo9e but less than 2 months (iii 2 months and abo9e but less than C ) months (i') C months and abo9e 3ate of dama&es in : per annum of the amount due %N 1&N 1%N '%N G

P#"4%*'* that the Corporation# in relation to a *actory or establishment )hich is declared as sic8 industrial company and in respect o* )hich a rehabilitation scheme has been sanctioned by the Hoard *or Industrial and >inancial Reconstruction# may G/

(a) in case o* a change o* management including trans*er o* underta8ing(s) to )or8er(s) coAoperati9e or in case o* merger or amalgamation o* sic8 industrial company )ith a healthy company# completely )ai9e the damages le9ied or le9iable5 (b) in other cases# depending on its merits# )ai9e up to %& per cent damages le9ied or le9iable5 (c) in e(ceptional hard cases# )ai9e either totally or partially the damages le9ied or le9iable.< 22:R'7%.$'# "- E/2&"3''. 4'. (1) E9ery employer shall maintain a register in >orm I in respect o* e9ery employee o* his *actory or establishment. 2%:(1a) E9ery immediate employer shall maintain a register in >orm 2%a[; in respect o* e9ery employee engaged by him and submit the same to the principal employer be*ore the settlement o* any amount payable under subAsection (1) o* section 21 o* the Act.< (') E9ery employer shall preser9e e9ery register maintained under this regulation a*ter it is *illed# *or a period o* *i9e years *rom the date o* last entry therein. (4) The employer shall gi9e a reasonable opportunity to any o* his employees# i* he so desires# to see entries in respect o* such employee in this register once a month.< O$!'# /"*'. "- 2(3/')$. "- 1")$#%65$%"), 44. !ub@ect to the directions o* the !tanding Committee# the DirectorA"eneral may# i* he thin8s *it and sub@ect to such terms and conditions as he may impose# appro9e o* any arrangement# 2C:;;;<# )hereby contributions are paid at times or in a manner other than those speci*ied in these regulations and such arrangement may include pro9ision *or the payment to the Corporation o* such *ees as may be determined by him to represent the estimated additional e(penses to Corporation# and may re.uire such deposit o* money by )ay o* security as he may determine. 42. 2I:;;;< 4%. 23:;;;< 2$:E/2&"3/')$ -"# 2(#$ "- ( 0(7' 2'#%"*, 4C. Fhere an employee is employed by an employer *or part o* a )age period# the contributions in respect o* such )age period# shall *all due on the last day o* the employment by such employer in that )age period.< 4I. %&:;;;<

S1!'/' 63 9"%)$ '/2&"3'#., 43. Fhere an employee is ordinarily employed by t)o or more employers in a %1:)age period< the employers o* such an employee may# i* they thin8 *it# submit to the Corporation a scheme *or the payment o* the contributions in respect o* such employee and the Corporation may# i* it is satis*ied that the scheme is such as )ill secure the due payment o* the contributions# appro9e such a scheme sub@ect to such terms and condition as it may thin8 necessaryG P#"4%*'* that i* no such scheme is submitted to or appro9ed by the Corporation# the Corporation may speci*y that any one o* such employers shall be treated as the employer *or the purposes o* the pro9isions o* the Act and the regulation relating to contributions# and in such a case the contribution *or any %1:)age period< shall *all due on the last day o* the %1:)age period< on )hich an employee )as employed by the employer so speci*ied. R'1;")%)7 "- 0(7'. "- '/2&"3'' '/2&"3'* 63 $0" "# /"#' '/2&"3'#. %) $!' .(/' %'[0(7' 2'#%"* , 4$. Fhere an employee is employed by an employer *or only a part o* the %':)age period< or )here an employee is employed by t)o or more employers in a %':)age period<# only the )ages payable to him *or the days up to an including the day on )hich the contribution *alls due *or that %':)age period< shall be ta8en into account in rec8oning )ages *or the purposes o* determining the a9erage daily )ages o* the employee *or that %':)age period.< %4:R'-5)* "- 1")$#%65$%") '##")'"5.&3 2(%*, 2&. (1) Any contribution paid by a person under the erroneous belie* that the contributions )ere payable by that person under the Act may be re*unded )ithout interest by the Corporation to that person# i* application to that e**ect is made in )riting be*ore the commencement o* the bene*it period corresponding to the contribution period in )hich such contribution )as paid. (') Fhere any contribution has been paid by a person at a rate higher than that at )hich it )as payable the e(cess o* the amount so paid o9er the amount payable may be re*unded )ithout interest by the Corporation to that person# i* application to that e**ect is made be*ore the commencement o* the bene*it period corresponding to the contribution period in )hich such contribution )as paid. (4) In calculating the amount o* any re*und to be made under this regulation there may be deducted the amount# i* any# paid to any person by )ay o* bene*it on the basis o* the contribution erroneously paid and *or the re*und o* )hich the application is made. (2) Fhere the )hole or part o* the amount o* any contribution re*erred to in subA regulations (1) and (')# )as reco9ered *rom an immediate employer or deducted *rom the )ages o* an employee by the principal employer# he shall# on getting the re*und o* the amount *rom the Corporation be liable to pay bac8 the amount so reco9ered or deducted to the person *rom )hom the amount )as so reco9ered or deducted.

(%) Applications *or re*und under this regulation shall be made in such *orm and in such manner and shall be supported by such documents as the DirectorA"eneral may# *rom time to time# determine.< 21. %2:;;;< 2'. %2:;;;< 24. %2:;;;< CHAPTER III 55[8ENE:ITS CBAI?! C&(%/. -"# 6')'-%$., 22. E9ery claim *or a bene*it payable under the Act shall be made in )riting# in accordance )ith these regulations# to the appropriate %%a[,ranch 7**ice on the *orm appropriate *or the purpose o* the bene*it *or )hich the claim is made or in such other manner as the appropriate o**ice may# sub@ect to its being in )riting# accept as su**icient in the circumstances o* any particular case or class o* cases. Assistance *or *illing in the *orm o* claim in case o* insured persons )ho cannot do so themsel9es shall be pro9ided at the %%a[,ranch 7**ices o* the Corporation. <!') 1&(%/ 6'1"/'. *5', 2%. A claim *or any bene*it under the Act shall *or the purposes o* section II o* the Act# becomes due on the *ollo)ing days G/ (a) >or sic8ness bene*it or *or disablement bene*it *or temporary disablement *or any period# on the date o* the issue o* the medical certi*icates in respect o* such periods5 pro9ided that in cases )here a person is not entitled to sic8ness bene*it *or the *irst t)o days o* sic8ness# the due date shall be de*erred by such days. (b) >or maternity bene*it/ (i) in case o* con*inement# on the date o* issue# in accordance )ith these regulations# o* certi*icate o* e(cepted con*inement or on the day si( )ee8s preceding the e(pected date o* con*inement so certi*ied )hiche9er is later or# i* no such certi*icate is issued# on the date o* con*inement5 and (ii) in case o* miscarriage and in case o* sic8ness arising out o* pregnancy# con*inement# premature birth o* child or miscarriage# on the date o* issue o* the medical certi*icate o* such miscarriage or sic8ness# as the case may be5 (c) *or %I:*irst payment o*< disablement bene*it *or permanent disablement# on the date in )hich an insured person is declared as permanently disabled in accordance )ith the Act and these regulations5 and %C:(d) *or %I:*irst payment o*< dependents bene*it# on the date o* the death o* the insured person in respect o* )hose death the claim *or such bene*it arises or# )here

disablement bene*it )as payable *or that date# on the date *ollo)ing the date o* death or# )here the bene*iciary becomes entitled to a claim on any subse.uent date# on the date on )hich he becomes so entitled5< %I:e) *or subse.uent payments o* disablement bene*it *or permanent disablement and *or subse.uent payment o* dependents bene*it# the last date o* the month to )hich the claim relates5< (f) *or *uneral %3:e(penses< on the date o* the death o* the insured person in respect o* )hose death the claim *or such bene*it arises. A4(%&(6%&%$3 "- 1&(%/ -"#/., 2C. Claim *orm shall be a9ailable to intending claimants *rom such persons and such o**ices o* the Corporation as it may appoint or authorise *or that purpose# and shall be supplied *ree o* charge. C&(%/ ") 0#")7 -"#/, 2I. Fhere a claim *or any bene*it has been made on an appro9ed *orm other than the *orm appropriate to the bene*it claimed# the Corporation may treat the claim as i* it )as made on the appropriate *orm5 pro9ided that the Corporation may in any such case re.uire the claimant to complete the appropriate *orm. E4%*')1' %) .522"#$ "- 1&(%/, 23. E9ery person )ho ma8es a claim *or any bene*it shall in addition to the medical certi*icate and other *orms speci*ically re.uired under these regulations# *urnish such other in*ormation and e9idence *or the purpose o* determining the claim as may be re.uired by the appropriate o**ice# and# i* reasonably so re.uired# shall *or that purpose attend at such o**ice or place as the appropriate o**ice may direct. D'-'1$%4' 1&(%/, 2$. I*# in absence o* due signature or o* due certi*ication# a claim is de*ecti9e on the date o* its receipt by an o**ice o* the Corporation the o**ice o* the Corporation may in its discretion re*er the claim to the claimant and i* the *orm is returned duly signed andKor certi*ied )ithin three months *rom the date on )hich it )as so re*erred# the o**ice may treat the claim as i* it had been duly made in the *irst instance. C&(%/ -"# %)(22#"2#%($' 6')'-%$, %&. Fhere it appears that a person )ho has made a claim *or any bene*it payable under the Act# may be entitled to a bene*it other than that )hich he has claimed# any such claim may be treated as a claim in the alternati9e *or that other bene*it. A5$!"#%$3 -"# 1'#$%-3%)7 '&%7%6%&%$3 "- 1&(%/()$.,

%1. The authority )hich is to certi*y the eligibility o* claimants shall be the appropriate %%a[,ranch 7**ice in respect o* maternity# sic8ness# temporary disablement %$:bene*its and *uneral e(penses< and the appropriate Regional 7**ice# in respect o* permanent disablement and dependent s bene*its. C&:8')'-%$. 0!') 2(3(6&' %'. (1) Any bene*it payable under the Act shall be paid/ (a) in the case o* sic8ness bene*it not later than I days5 C1:(b) in the case o* *uneral e(penses not later than 1% days5< (c) in the case o* *irst payment in respect o* maternity bene*it not later than 12 days5 (d) in the case o* the *irst payment in respect o* Temporary Disablement Hene*it not later than one month5 (e) in the case o* *irst payment o* Permanent Disablement Hene*it not later than one month5 (f) in the case o* *irst payment o* Dependents Hene*its not later than 4 months# a*ter the claim there*or together )ith the rele9ant medical or other certi*icates and any other documentary e9idence )hich may be called *or under these Regulations has been *urnished complete in all particular to the appropriate o**ice.< (') !econd and subse.uent payments in respect o* any maternity# temporary disablement# permanent disablement or dependents bene*it shall be paid along )ith the *irst payment in respect thereo* or )ithin the calendar month *ollo)ing the month to the )hole or part o* )hich they relate# )hiche9er is later sub@ect to production o* any documentary e9idence )hich may be re.uired under these regulations. (4) Fhere a bene*it payment is not made )ithin the time limits speci*ied in subA regulations (1) and (') abo9e# it shall be reported to the C':appropriate Regional 7**ice< and shall be paid as soon as possible. C4:(2) Hene*its under the Act shall be paid in cash at a %%a[,ranch 7**ice on such days and )or8ing hours# as may be *i(ed by the DirectorA"eneral# or such other o**icer o* the Corporation# as may be authorised by him *rom time to time in this behal*# or# at the option o* the claimant and sub@ect to deduction o* the cost o* remittance# by means o* postal money orders or other orders payable through a post o**ice# or by any other means# )hich the appropriate o**ice may in the circumstances o* any particular case consider appropriateG P#"4%*'* that the Corporation may )ai9e the deduction o* the cost o* remittance in such cases as the DirectorA"eneral may# *rom time to time# speci*y.< (%) Fhere the payment o* a bene*it is to be made at a %%a[,ranch 7**ice# such o**ice may insist upon the production o* the Identity Card or other document issued in lieu thereo* in respect o* the insured person.

C2:A6.$')$%") 4'#%-%1($%"), %'A. C%:(1)< E9ery employer shall *urnish to the appropriate o**ice such in*ormation and particulars in respect o* the abstention o* an insured person *rom )or8 *or )hich sic8ness bene*it CC:;;;< or disablement bene*it *or temporary disablement# as pro9ided under the Act has been claimed or paid# in >orm =o. CCa[10 and )ithin such time as the said o**ice may in )riting re.uire in the said *orm.< CI:(') E9ery employer shall *urnish to the appropriate o**ice such in*ormation and particulars in respect o* the abstention o* an insured )oman *rom )or8 *or )hich maternity bene*it as pro9ided under the Act has been claimed or paid# in >orm CCa[10 and )ithin such time as the said o**ice may in )riting re.uire in the said >orm.< CERTI>ICATI7= A=D CBAI?! >7R !IC-=E!! A=D TE?P7RARE DI!AHBE?E=T E4%*')1' "- .%1;)'.. ()* $'/2"#(#3 *%.(6&'/')$, %4. E9ery insured person# claiming sic8ness bene*it or disablement bene*it *or temporary disablement# shall *urnish e9idence o* sic8ness or temporary disablement in respect o* the days o* his sic8ness or temporary disablement by means o* a medical certi*icate gi9en by an Insurance ?edical 7**icer in accordance )ith these regulations in the *orm appropriate to the circumstances o* the caseG P#"4%*'* that in areas )here arrangement *or medical bene*it under the Employees !tate Insurance Act ha9e not been made or other)ise i* in its opinion the circumstances o* a particular case so @usti*y# the Corporation may accept any other e9idence o* sic8ness or temporary disablement in the *orm o* a certi*icate issued by the medical o**icer o* the !tate "o9ernment# local body or other medical institution# or a certi*icate issued by any registered medical practitioner containing such particulars and attested in such manner as may be speci*ied by the DirectorA"eneral in this behal*. P'#."). 1"/2'$')$ $" %..5' /'*%1(& 1'#$%-%1($', %2. =o medical certi*icate under these regulations shall be issued e(cept by the Insurance ?edical 7**icer to )hom an insured person has been allotted or by an Insurance ?edical 7**icer attached to a dispensary# hospital# clinic or other institution to )hich and insured person is allotted and such Insurance ?edical 7**icer shall e(amine and i* in his opinion the condition o* the insured person so @usti*ies# issue to such insured person *ree o* charge# any medical certi*icates reasonably re.uired by such insured person under or *or the purposes o* the Act or any other enactment or these regulationsG P#"4%*'* that an Insurance ?edical 7**icer may issue a medical certi*icate under these regulations to a insured person )ho is not allotted to him or to the dispensary# hospital# clinic or other institution to )hich he is attached# i* such o**icer is satis*ied that in the circumstances o* any particular case the insured person cannot reasonably be e(pected to get medical bene*it *rom the Insurance ?edical 7**icer or the dispensary# hospital# clinic or other institution to )hich such insured person has been allotted5 and such certi*icate shall also be issued *ree o* charge G

P#"4%*'* -5#$!'# that an insured person shall not be granted a medical certi*icate unless he produces to the Insurance ?edical 7**icer his Identity Card or such other 0Documents1 as under these regulations# may ha9e been issued in lieu thereo*. M'*%1(& 1'#$%-%1($', %%. The appropriate *orm o* a medical certi*icate shall be *illed in in8 or other)ise as may be speci*ied by the DirectorA"eneral by the Insurance ?edical 7**icer in his o)n hand)riting and shall contain a concise statement o* the disease or disablement )hich in the opinion o* the Insurance ?edical 7**icer necessitates abstention *rom )or8 on medical grounds or renders the person temporarily incapable o* )or8. The statement o* the disease or disablement in the medical certi*icate shall speci*y the nature thereo* as precisely as the Insurance ?edical 7**icer s 8no)ledge o* the condition o* the insured person at the time o* the e(amination permits. T%/' "- 7#()$%)7 /'*%1(& 1'#$%-%1($', %C. (a) An Insurance ?edical 7**icer shall gi9e the medical certi*icate to an insured person at the time o* the e(amination to )hich it relates5 )here he is pre9ented *rom so doing he shall send the certi*icate to the insured person )ithin t)entyA*our hours therea*ter. (b) =o *urther medical certi*icate relating to the same e(amination shall be issued# e(cept )here a duplicate o* such certi*icate is re.uired# in )hich case it shall be issued *ree o* charge and clearly mar8ed 0Duplicate1. C3:M'*%1(& 1'#$%-%1($' ") -%#.$ '+(/%)($%"), %I. Fhere the e(amination is the *irst e(amination in respect o* a spell o* sic8ness or a spell o* temporary disablement# the medical certi*icate shall be in the *orm o* a *irst certi*icate (>orm C3a[7 ) and shall be only in respect o* the date o* e(aminationG C$:P#"4%*'* that )here the insured person# )ho needs abstention *rom )or8 on the day o* e(amination# states that he has been actually sic8 or temporarily disabled on a day earlier than the date o* his *irst e(amination# the Insurance ?edical 7**icer may# i* he is satis*ied as to the truth o* the statement that the insured person )as unable to present himsel* *or medical e(amination earlier *or reasons beyond his control# certi*y incapacity *or )or8 on the date preceding the date o* e(aminationG< P#"4%*'* C$:-5#$!'#< that )here in the opinion o* the Insurance ?edical 7**icer# the insured person is li8ely to become *it to resume )or8 on a date not later than the third day a*ter the date o* the e(amination# the *irst certi*icate may be issued in respect o* the entire spell o* sic8ness or temporary disablement# and# in such a case# it shall speci*y the date on )hich the insured person )ill# in his opinion# be *it to resume )or85 such a certi*icate shall# not)ithstanding anything contained in the regulations# be also treated as a *inal certi*icate.<

:%)(& /'*%1(& 1'#$%-%1($', %3. I* at the date o* the e(amination to )hich a medical certi*icate other than a *irst certi*icate relates# the insured person in the opinion o* the Insurance ?edical 7**icer is# or )ill become on a date not later than the third day a*ter that date# *it to resume )or8# that certi*icate shall be in the *orm o* a *inal certi*icate (>orm C3a[7 ). I)$'#/'*%($' 1'#$%-%1($', %$. I* the *inal certi*icate is not issued )ithin se9en days o* the date o* the *irst certi*icate# an insured person shall# e(cept )here the case is co9ered by regulation C1# submit certi*icates in the *orm o* intermediate certi*icates (>orm C3a[7 ) at inter9als o* not more than se9en days each# commencing *rom the date o* the *irst certi*icate. :%)(& /'*%1(& 1'#$%-%1($' 6'-"#' 1"//')1%)7 0"#; -"# 0(7'., C&. E9ery insured person shall obtain a medical certi*icate in the *orm o* a *inal certi*icate be*ore he ta8es up any )or8 *or )ages. I)$'#/'*%($' 1'#$%-%1($' -"# ( &")7'# 2'#%"* I&:;;;<. C1. Fhen temporary disablement I1:or sic8ness< has continued *or not less than t)entyA eight days and the Insurance ?edical 7**icer is satis*ied that such disablement I1:or sic8ness< is li8ely to continue *or a long period and that# o)ing to the nature o* the disablement I1:or sic8ness< e(amination and treatment at inter9als o* more than one )ee8 )ill be su**icient# the insured person may# unless other)ise directed by the appropriate o**ice# *urnish medical certi*icates in the *orm o* special intermediate certi*icates (>orm I1a[ ) at inter9als o* such longer periods not e(ceeding *our )ee8s as may be speci*ied by the Insurance ?edical 7**icer. C'. :;;;< :"#/ "- 1&(%/ -"# .%1;)'.. "# $'/2"#(#3 *%.(6&'/')$, C4. An insured person intending to claim sic8ness bene*it or disablement bene*it *or temporary disablement shall submit to the appropriate %%a[,ranch 7**ice by post or other)ise# a claim *or bene*it in one o* the I1a[/orm 9 appropriate to the circumstances o* the case together )ith the appropriate medical certi*icateG I':P#"4%*'* that )here only one claim in I1a[/orm 9 is submitted in respect o* more than one certi*icates# such I1a[/orm 9 shall be deemed to be appropriate to all such certi*icates.< :(%&5#' $" .56/%$ /'*%1(& 1'#$%-%1($', C2. I* a person )ho intends to claim sic8ness bene*it or disablement bene*it *or temporary disablement *ails to submit to the appropriate %%a[,ranch 7**ice by post or other)ise the *irst medical certi*icate or any subse.uent medical certi*icate )ithin a period o* three

days *rom the date o* issue o* such certi*icate he shall not be eligible *or that bene*it in respect o* any period (i) in the case o* a *irst certi*icate# more than three days be*ore the date on )hich the certi*icate is submitted to the appropriate %%a[,ranch 7**ice5 (ii) in the case o* a subse.uent certi*icate# more than *ourteen days be*ore the date on )hich such subse.uent certi*icate is submitted to the appropriate %%a[,ranch 7**ice G I4:P#"4%*'* that the appropriate Regional 7**ice I4:or other o**ice as authorised by the DirectorA"eneral< may rela( all or any o* the pro9isions o* this regulation in any particular case# i* it is satis*ied that the delay in submitting a certi*icate )as due to bona fide reasons.< DI!AHBE?E=T HE=E>IT N"$%1' "- (11%*')$, C%. (i) E9ery insured person )ho sustains personal in@ury caused by accident arising out o* and in the course o* his employment in a *actory or establishment shall gi9e notice o* such in@ury either in )riting or orally# as soon as practicable a*ter the happening o* the accidentG P#"4%*'* that any such notice re.uired to be gi9en by an insured person may be gi9en by some other person acting on his behal*. I2:Explanation * =o such notice shall be re.uired to be gi9en by an insured person i* an employment in@ury is caused by any 7ccupational Disease speci*ied in !chedule III to the For8men s Compensation Act# 1$'4.< (ii) E9ery such notice shall be gi9en to the employer or to a *oreman or to other o**icial under )hose super9ision the insured person is employed at the time o* the accident or any other person designated *or the purpose by the employer and shall contain the appropriate particulars. (iii) Any entry o* the appropriate particulars o* the accident made in a boo8 8ept *or that purpose in accordance )ith the ne(t *ollo)ing regulation shall# i* made as soon as practicable a*ter the happening o* the accident by the insured person or by some other person acting on his behal*# be su**icient notice o* the accident *or the purposes o* these regulations. (i') In this regulation and the ne(t *ollo)ing regulation# the e(pression Oappropriate particulars means the particulars indicated belo)/ (a) *ull name# insurance number# se(# age# address# occupation# department and shi*t o* the in@ured person5 (b) date and time o* accident5 (c) place )here accident happened5 (d) cause and nature o* in@ury5 (e) name# address and occupation o* the person gi9ing the notice# i* he is other than the in@ured person5 (f) a statement o* )hat e(actly the in@ured person )as doing at the time o* in@ury5

(&) name# addresses and occupation o* t)o persons )ho )ere present at the spot )hen accident happened5 and (h) remar8s# i* any. M(%)$')()1' "- (11%*')$ 6"";, CC. E9ery employer shall/ (i) 8eep a boo8 readily accessible (hereina*ter called Othe Accident Hoo8 ) in >orm I2a[11 # in )hich the appropriate particulars o* any accident causing personal in@ury to an insured person may be entered5 (ii) Preser9e e9ery such boo8 )hen it is completed *or a period o* *i9e years *rom the date o* the last entry thereonG I%:P#"4%*'* that it shall not be necessary to enter in the said Accident Hoo8 particulars o* any employment in@ury caused by an 7ccupational Disease speci*ied in !chedule III to the For8men s Compensation Act# 1$'4.< N"$%1' "$!'#0%.' $!() 63 () ')$#3 %) (11%*')$ 6"";, CI. I* notice o* an employment in@ury under regulation C% is gi9en other)ise than by an entry in the Accident Hoo8 it shall be the duty o* the employer or any other person to )hom such notice is gi9en under that regulation to ma8e an appropriate entry in the boo8 in respect o* the accident to )hich the notice relates immediately a*ter such notice is recei9ed# and )here the notice is recei9ed other)ise than in )riting# read o9er the particulars to the person )ho gi9es the notice and obtains his signature or thumbA impression on the Accident Hoo8. R'2"#$ "- (11%*')$ 63 () '/2&"3'#, C3. E9ery employer shall send a report in >orm I%a[17 to the nearest %%a[,ranch 7**ice and to the nearest Insurance ?edical 7**icer/ (i) immediately i* the in@ury is serious# i2e2, it is li8ely to cause death or permanent disablement or loss o* a member5 and (ii) in any other case )ithin '2 hours a*ter the receipt o* the notice under regulation C% or o* the time )hen the accident came to the notice o* the employer or o* a *oreman or other o**icial under )hose super9ision the insured person )as employed at the time o* the accident or any other person designated *or the purpose by the employerG P#"4%*'* that in case o* a serious in@ury# and particularly )hen the in@ury results in death at the place o* employment# the report to the Insurance ?edical 7**icer and the 55a[,ranch 7**icer shall be sent through a special messenger# or other)ise# as speedily as may be practicable under the circumstancesG P#"4%*'* -5#$!'# that )here a report o* the accident is made by the employer under the >actories Act# 1$23# the report to the 55a[,ranch 7**ice and to the Insurance ?edical 7**icer may be made in the same *orm as is prescribed under the >actories Act# 1$23# pro9ided that all the additional in*ormation re.uired under >orm I%b[17 is added theretoG

IC:P#"4%*'* -5#$!'# that it shall not be necessary *or the employer to send a report in >orm I%b[17 i* an employment in@ury is caused by any 7ccupational Disease speci*ied in !chedule III to the For8men s Compensation Act# 1$'45 but the employer shall *urnish on demand to the appropriate 55a[,ranch 7**ice# )ithin such reasonable period as may be speci*ied# such in*ormation and particulars as shall be re.uired o* the nature o* and other rele9ant circumstances relating to any employment speci*ied in !chedule III to the For8men s Compensation Act# 1$'4.< E/2&"3'# $" (##()7' -%#.$ (%*, C$. E9ery employer shall arrange *or such *irst aid and medical care and transport *or obtaining such aid and care as the circumstances o* the accident may re.uire till the in@ured person is seen by the Insurance ?edical 7**icer and such employer shall be entitled to reimbursement in respect o* e(penses thereby incurred by him but not e(ceeding such scale o* e(penses as may be speci*ied by the Corporation *rom time to timeG P#"4%*'* that i* the employer is re.uired to pro9ide such medical aid *ree o* charge under any other enactment# he shall not be entitled to any reimbursement o* e(penses. E/2&"3'# $" -5#)%.! -5#$!'# 2(#$%15&(#. "- (11%*')$, I&. E9ery employer shall *urnish to the appropriate o**ice such *urther in*ormation and particulars o* an accident and )ithin such time as the said o**ice may# in )riting# re.uire. D%#'1$%"). 63 $!' C"#2"#($%"), I1. E9ery claimant *or and e9ery bene*iciary in receipt o* disablement bene*it shall comply )ith e9ery direction gi9en to him by the appropriate Regional 7**ice )hich re.uires him either/ (i) to submit himsel* to a medical e(amination by such medical authority as may be appointed by that o**ice *or the purpose o* determining the e**ect o* the rele9ant employment in@ury or the treatment appropriate to the rele9ant in@ury or loss o* *aculty# or (ii) to attend any 9ocational training courses or industrial rehabilitation courses pro9ided by any institution maintained by any "o9ernment# local authority or any public or pri9ate body# recognised *or the purpose by the Corporation and considered appropriate by it in his case. R'-'#')1' $" ( M'*%1(& 8"(#*, I'. A re*erence to the ?edical Hoard may be made/ II:(a) at any time not later than t)el9e months# in cases )here claim *or temporary disablement bene*it is made *or an employment in@ury# *rom the date o* the *inal certi*icate issued in respect o* the spell o* temporary disablement commencing on or immediately a*ter the day o* the occurrence o* that in@ury# or *rom the date o* the occurrence o* an employment in@ury in cases )here temporary disablement bene*it

not ha9ing been claimed claim *or permanent disablement is made on the basis thereo*# by the appropriate Regional 7**ice at the instance o* the disabled person or the employer or any recognised employee s unionG P#"4%*'* that such re*erence may be made by the appropriate Regional 7**ice a*ter the e(piry o* the period prescribed as a*oresaid i* it is satis*ied that the applicant )as pre9ented by su**icient cause *rom applying *or the ma8ing o* the re*erence in timeG P#"4%*'* -5#$!'# that in the e9ent o* the claim *or Temporary Disablement Hene*it being re@ected by the Corporation but a*ter)ards granted by the Employees Insurance Court in respect o* in@uries resulted in Permanent disablement# the limit o* 1' months )ill apply *rom the date o* the order o* the Employees Insurance Court granting the claim o* the insured person *or Temporary Disablement Hene*it# or< (b) by the Corporation# (i) at any time# on the recommendation o* an Insurance ?edical 7**icer# and (ii) on its o)n initiati9e# a*ter the e(piry o* the period o* t)entyAeight days *rom the *irst date on )hich the claimant )as rendered incapable o* )or8 by the rele9ant employment in@ury. R'2"#$ "- M'*%1(& 8"(#*, I4. The ?edical Hoard shall a*ter e(amining the disabled person send its decision on such *orm as may be speci*ied by the DirectorA"eneral# to the appropriate Regional 7**ice. The disabled person shall be in*ormed in )riting o* the decision o* the ?edical Hoard and the bene*it# i* any# to )hich the disabled person shall be entitled. O1152($%")(& D%.'(.', I2. Any .uestion )hether an employment in@ury is caused by an 7ccupational Disease speci*ied in the Third !chedule to the Act shall be determined by a !pecial ?edical Hoard )hich shall e(amine the disabled person and send a report in such *orm as may be prescribed by the Director "eneral in this behal* to the appropriate Regional 7**ice stating G/ (a) )hether the disabled person is su**ering *rom one or more o* the diseases speci*ied in the said schedule5 (b) )hether the rele9ant disease has resulted in permanent disablement5 (c) )hether the e(tent o* loss o* earning capacity can be assessed pro9isionally or *inally5 (d) the assessment o* the proportion o* loss o* earning capacity and in case o* pro9isional assessment# the period *or )hich such assessment shall hold good. All assessments )hich are pro9isional may be re*erred to the !pecial ?edical Hoard *or re9ie) by the appropriate Regional 7**ice not later than the end o* the period ta8en into account by the pro9isional assessment. Any decision o* the !pecial ?edical Hoard may be re9ie)ed by it at any time. The disabled person shall be in*ormed in )riting o* the

decision o* the !pecial ?edical Hoard by the appropriate Regional 7**ice and the bene*it# i* any# to )hich the insured person shall be entitled. I3:C").$%$5$%") "- M'*%1(& 8"(#*/S2'1%(& M'*%1(& 8"(#*., I%. ?edical Hoards *or the purposes o* the Act and the !pecial ?edical Hoards *or the purposes o* regulation I2 shall be constituted by the Corporation and )here it so desires it may approach the !tate "o9ernment *or setting up the same and shall consist o* such persons# ha9e such @urisdiction and *ollo) such procedure as the DirectorA"eneral may *rom time to time decide.< I$:A22'(& T#%65)(&., IC. >or the purposes o* regulation I2# an Appeal Tribunal shall be constituted by the !tate "o9ernment and shall consist o* a @udicial o**icer o* the !tate "o9ernment being a person other than the @udge o* an Employees Insurance Court# )ho shall be assisted by the *ollo)ing persons to be selected by him as assessors G/ (a) 7ne or more medical e(perts5 (b) 7ne or more o**icial o* or members o* Trade +nion or +nions.< 3&:31:S56/%..%") "- 1&(%/. -"# 2'#/()')$ *%.(6&'/')$ 6')'-%$,< ICA. An insured person )ho has been declared to be permanently disabled by a ?edical Hoard or by an Appeal Tribunal shall submit by post or other)ise# to the appropriate %%a[,ranch 7**ice a claim# co9ering# e(cept in the case o* a *irst payment# a period o* one or more complete calendar months in >orm 31a[14 *or claiming permanent disablement bene*it.< 3':3'a:C"//5$($%") "- 2'#/()')$ *%.(6&'/')$ 6')'-%$,< ICH. 34:(1) An insured person )hose permanent disablement has been assessed as *inal and )ho has been a)arded permanent disablement bene*it at a rate not e(ceeding Rs. 1.%& per day may apply *or commutation o* permanent disablement bene*it into a lump sumG P#"4%*'* that the insured person )hose permanent disablement has been assessed as *inal and the bene*it rate e(ceeds Rs. 1.%& per day may also apply *or commutation o* permanent disablement bene*it into lump sum sub@ect to the condition that the total commuted 9alue o* the lump sum permanent disablement bene*it does not e(ceed Rs. 1&#&&& at the time o* commencement o* *inal a)ard o* his permanent disability G P#"4%*'* -5#$!'# that the cases *alling under clause (4) o* this regulation )here commutation has been re*used because the insured person did not ha9e a9erage e(pectation o* li*e# shall not be reopened.< (') Fhere such an application is made )ithin C months o* the date on )hich he can opt *or commutation herea*ter called the 0date o* possible option1 32:permanent disablement bene*it< shall be commuted into a lump sum.

(4) Fhere such an application is made a*ter e(piry o* si( months *rom the date o* possible option# 32:permanent disablement bene*it< may be commuted into lump sum i* the corporation is satis*ied that the insured person has an a9erage e(pectation o* li*e *or his age. >or this purpose# the insured person shall# i* so re.uired by the appropriate o**ice# present himsel* *or e(amination by such medical authority as the DirectorA"eneral may# by general or special order# speci*y. (2) >or the purpose o* this regulation# the date o* possible option shall mean/ (i) in the case o* a person )ho# on the date on )hich this regulation comes into *orce# is in receipt o* permanent disablement bene*it co9ered by subAregulation (1) the date o* coming into *orce o* this regulation5 (ii) in the case o* any other insured person# the date on )hich assessment o* permanent disablement co9ered by subAregulation (1)# is communicated to him by the appropriate Regional 7**ice. (%) The amount o* lump sum admissible under this regulation shall be determined by multiplying the daily rate o* permanent disablement bene*it by the *igure indicated in Column ' o* the !chedule III to these regulations# corresponding to the age on last birthday o* the insured person on the date on )hich his application *or commutation is recei9ed in the appropriate o**ice and on and *rom that date 3%:the< permanent disablement bene*it shall cease to be payable to him< G 3C:P#"4%*'* that )here no proo* o* age has been submitted as re.uired by the appropriate o**ice or i* submitted# has not been accepted as satis*actory by the appropriate o**ice# the corresponding age as a*oresaid o* the insured person shall be the age as estimated by the ?edical Hoard on the date o* e(amination ad@usted by the period inter9ening bet)een the date o* e(amination by the ?edical Hoard and the date on )hich the application *or commutation )as recei9ed in the appropriate o**iceG P#"4%*'* -5#$!'# that the age so estimated by the ?edical Hoard shall also operate against any proo* o* age that may be submitted a*ter the time allo)ed *or the purpose to the insured person by the appropriate o**ice be*ore re*erence o* his case to the ?edical Hoard.< DEPE=DE=T! HE=E>IT R'2"#$ "- *'($! "- %).5#'* 2'#.") 63 '/2&"3/')$ %)95#3, II. In case o* death o* an insured person as a result o* an employment in@ury/ (a) i* the death occurs at the place o* employment the employer shall# and (b) i* the death occurs at any other place# a dependent intending to claim dependants bene*it shall# or (c) any other person present at the time o* death may# immediately report the death to the nearest %%a[,ranch 7**ice and to the nearest dispensary# hospital# clinic or other institution )here medical bene*it under the Act is a9ailable.

D%.2".(& "- 6"*3 "- () %).5#'* 2'#.") *3%)7 63 '/2&"3/')$ %)95#3, I3. Fhere an insured person dies as a result o* an employment in@ury sustained as an employee under the Act# the body o* the insured person shall not be disposed o* until the body has been e(amined by# an Insurance ?edical 7**icer# )ho )ill also arrange a postA mortem e(amination# i* considered necessary# in coAoperation )ith any other e(isting agencyG P#"4%*'* that i* an Insurance ?edical 7**icer is unable to arri9e *or the e(amination )ithin 1' hours o* such death the body may be disposed o* a*ter obtaining a certi*icate *rom such medical o**icer or practitioner as may be a9ailableG P#"4%*'* -5#$!'# that nothing contained in this regulation shall be in derogation o* any po)er con*erred on a coroner under any la) *or the time being in *orce or on the o**icerA inAcharge o* a police station or some other police o**icer under 3I:section 1I2 o* the Code o* Criminal Procedure# 1$I4 (' o* 1$I2).< I..5' "- *'($! 1'#$%-%1($', I$. An Insurance ?edical 7**icer attending the disabled person at the time o* his death or the Insurance ?edical 7**icer )ho e(amines the body a*ter the death or the ?edical 7**icer )ho attended the insured person in a hospital or other institution )here such disabled person died# shall issue *ree o* charge a death certi*icate in >orm 3Ia[1" to the dependants o* the deceased and shall send a report to the appropriate Regional 7**ice. S56/%..%") "- 1&(%/ -"# *'2')*()$. 6')'-%$, 3&. (1) A claim *or dependants bene*it shall be submitted to the appropriate %%a[,ranch 7**ice by post or other)ise in >orm 3Ib[18 by the dependant or dependants concerned or by their legal representati9e or# in case o* a minor# by his guardian# and such claim shall be supported by documents pro9ing/ (i) that the death is due to an employment in@ury5 33:(ii) that the person claiming is a dependent entitled to claim as pro9ided in rule %3 o* the Employees !tate Insurance (Central) Rules# 1$%&5< (iii) the age o* the claimant5 (i') the in*irmity o* the dependent claiming to be in*irm )ithin the pur9ie) o* 3$:rule %3 o* the Employees !tate Insurance (Central) Rules# 1$%&< by a certi*icate o* such medical or other authority as the DirectorA"eneral may# by a general or special order speci*y in this behal* G P#"4%*'* that )here the appropriate Regional 7**ice is satis*ied about the bona fides o* the applicant or about the truth o* the *acts relating to any o* the matters mentioned abo9e# one or more o* the documents may be dispensed )ith. (') The *ollo)ing may be accepted as proo* o* age/ (a) certi*ied e(tract *rom an o**icial record o* births sho)ing the date and place o* birth and *ather s name5 (b) original horoscope prepared soon a*ter birth5

(c) certi*ied e(tract *rom baptismal register5 (d) certi*ied e(tract *rom school record sho)ing the date o* birth and *ather s name5 (e) such other e9idence as may be acceptable to the appropriate Regional 7**ice in the circumstances o* a particular case. N"$%1' -"# *'2')*()$. 6')'-%$, 31. 7n receipt o* a claim or claims *or dependants bene*it in respect o* the death o* an insured person and# a*ter ma8ing such in.uires as may be necessary about the circumstances and cause o* death and about all persons# )ho may be entitled to dependants bene*it# the appropriate Regional 7**ice shall issue by registered post to such other persons# i* any# as appear on en.uiry to be entitled to dependants bene*it# and )ho ha9e not yet submitted a claim *or such bene*it a notice *or submission o* claims *or dependants bene*it )ithin a period o* thirty days *rom the date o* such notice. The notice shall indicate inter alia the rele9ant pro9isions o* the Act and regulations and the procedure *or submission o* a claim *or dependants bene*it. I)$%/($%") "- *'1%.%") #'7(#*%)7 *'2')*()$. 6')'-%$, 3'. As soon as possible a*ter the e(piry o* the period during )hich claims can be submitted in terms o* the notice issued under regulation 31# the appropriate Regional 7**ice shall intimate by registered post the decision o* the Corporation in regard to the claim o* each o* the dependants in )riting to the dependants concerned or to his legal representati9e# or# in the case o* a minor# to his guardian. D($' "- (11#5(& "- *'2')*()$. 6')'-%$, 34. The dependant s bene*it shall accrue *rom the date o* the death in respect o* )hich the bene*it is payable# $&:or# )here disablement bene*it )as payable *or that date *rom the date *ollo)ing the date o* death.< $1:S56/%..%") "- 1&(%/. -"# 2'#%"*%1(& 2(3/')$. "- *'2')*()$. 6')'-%$, 34A. Each dependant )hose claim *or dependants bene*it is admitted under regulation 3'# shall submit to the appropriate %%a[,ranch 7**ice# by post or other)ise# a claim co9ering# e(cept in the case o* *irst or a *inal payment a period o* one or more complete calendar months in >orm $1a[1; . !uch claim may be made by the legal representati9e o* a bene*iciary or in the case o* a minor# by his guardian.< R'4%'0 "- *'2')*()$. 6')'-%$, 32. (1) The amounts payable as dependents bene*it in respect o* the death o* any insured person may be re9ie)ed by the appropriate Regional 7**ice at its o)n initiati9e# and shall be so re9ie)ed i* an application is made to that e**ect# under any o* the *ollo)ing circumstances/

(a) i* any o* the bene*iciaries ceases to be entitled to the dependants bene*it by reason o* marriage# reAmarriage# death# age or other)ise# or (b) i* a *resh dependant is admitted to the claim *or dependants bene*it by the birth o* a posthumous child# or (c) i*# a*ter the pre9ious decision as to the distribution o* the dependents bene*it )as ta8en# some *acts materially# a**ecting such distribution come to light. (') Any re9ie) under this regulation shall be made a*ter gi9ing due notice by registered post to each o* the dependants# stating therein the reasons *or the proposed re9ie) and gi9ing them an opportunity to submit ob@ections# i* any# to such re9ie). (4) !ub@ect to the pro9isions o* the Act and these regulations# the appropriate Regional 7**ice may# as a result o* such re9ie)# commence# continue# increase# reduce or discontinue *rom such date as it may decide the share o* any o* the dependants. 3%. $':;;;< A22"%)$/')$ "- ()"$!'# 75(#*%(), 3C. I* at any time the appropriate Regional 7**ice is satis*ied that a child )ho is in receipt o* dependants bene*it is being neglected by his guardian# not being a guardian appointed under the "uardian and Fards Act# 13$&# and the child s share o* the dependants bene*it is not being properly spent on his or her maintenance# the appropriate Regional 7**ice may direct that such share may be paid sub@ect to such conditions as it may speci*y to such other person as it deems *it and as in its opinion )ould utilise it *or the care and maintenance o* the child. ?ATER=ITE HE=E>IT N"$%1' "- 2#'7)()13, 3I. An insured )oman# )ho decides to gi9e notice o* pregnancy be*ore con*inement# shall gi9e such notice in >orm $1a[17 to the appropriate %%a[,ranch 7**ice by post or other)ise and shall submit# together )ith such notice# a certi*icate o* pregnancy in >orm '& gi9en in accordance )ith these regulations on a date not earlier than se9en days be*ore the date on )hich such notice is gi9en. C&(%/ -"# /($'#)%$3 6')'-%$ 1"//')1%)7 6'-"#' 1")-%)'/')$, 33. E9ery insured )oman claiming maternity bene*it be*ore con*inement shall submit to the appropriate %%a[,ranch 7**ice by post or other)ise/ (i) a certi*icate o* e(pected con*inement in >orm $'b[1 gi9en in accordance )ith these regulations# not earlier than *i*teen days be*ore the e(pected date o* con*inement5 (ii) a claim *or maternity bene*it in >orm $'c[19 stating therein the date on )hich she ceased or )ill cease to )or8 *or remuneration5 and (iii) )ithin thirty days o* the date on )hich her con*inement ta8es place# a certi*icate o* con*inement in >orm $'b[1 gi9en in accordance )ith these regulations.

C&(%/ -"# /($'#)%$3 6')'-%$ ")&3 (-$'# 1")-%)'/')$ "# -"# /%.1(##%(7', 3$. E9ery insured )oman claiming maternity bene*it *or miscarriage shall )ithin 4& days o* the date o* the miscarriage# and e9ery insured )oman claiming maternity bene*it a*ter con*inement# shall submit to the appropriate o**ice by post or other)ise a claim *or maternity bene*it in >orm $'c[19 together )ith a certi*icate o* con*inement or miscarriage in >orm $'b[1 gi9en in accordance )ith these regulations. C&(%/ -"# /($'#)%$3 6')'-%$ (-$'# $!' *'($! "- () %).5#'* 0"/() &'(4%)7 6'!%)* $!' 1!%&*, 3$A. >or the purposes o* the pro9iso to subAsection (') o* section %& o* the Act# the person nominated by the deceased insured )oman on >orm 1 or on such other >orm as may be speci*ied by the DirectorA"eneral in this behal* and i* there is no such nominee# the legal representati9e# shall submit to the appropriate o**ice by post or other)ise a claim *or maternity bene*it# as may be due# in >orm $'d[70 )ithin 4& days o* the death o* the insured )oman together )ith a death certi*icate in >orm $'e[71 gi9en in accordance )ith these Regulations. C&(%/ -"# /($'#)%$3 6')'-%$ %) 1(.' "- .%1;)'.. (#%.%)7 "5$ "- 2#'7)()13, 1")-%)'/')$, 2#'/($5#' 6%#$! "- 1!%&* "# /%.1(##%(7', 3$H. (1) E9ery insured )oman claiming maternity bene*it in case o* sic8ness arising out o* pregnancy# con*inement# premature birth o* child or miscarriage# shall submit to the appropriate o**ice by post or other)ise a claim *or bene*it in one o* the $4[/orm 9 appropriate to the circumstances o* the case together )ith the appropriate medical certi*icate in >orm $4a[7 or $4b[ # as the case may be# gi9en in accordance )ith these Regulations. (') The pro9isions o* regulations %% to C1 and C2 shall# so *ar as may be# apply in relation to a claim submitted and a certi*icate gi9en in accordance )ith this regulation as they apply to certi*ication and claims under those regulations. O$!'# '4%*')1' %) &%'5 "- ( 1'#$%-%1($', $&. The Corporation may accept any other e9idence in lieu o* a certi*icate o* pregnancy# e(pected con*inement# con*inement# death during maternity# miscarriage or sic8ness arising out o* pregnancy# con*inement# premature birth o* child or miscarriage by an Issurance ?edical 7**icer# i* in its opinion# the circumstances o* any particular case so @usti*y. N"$%1' "- 0"#; -"# #'/5)'#($%"), $1. E(cept as pro9ided in regulation 3$H e9ery insured )oman )ho has claimed maternity bene*it shall gi9e notice in >orm $4c[19 i* she does )or8 *or remuneration on any day during the period *or )hich maternity bene*it )ould be payable to her but *or her )or8ing *or remuneration.

D($' "- 2(3/')$ "- /($'#)%$3 6')'-%$, $'. ?aternity bene*it shall be payable *rom the date *rom )hich it is claimed pro9ided that such date does not precede the e(pected date o* con*inement by more than *ortyAt)o days# and that no )or8 is underta8en by the insured )oman *or remuneration. D%.=5(&%-%1($%") -"# /($'#)%$3 6')'-%$, $4. An insured )oman may be dis.uali*ied *rom recei9ing maternity bene*it i* she *ails )ithout good cause to attend *or or to submit hersel* to medical e(amination )hen so re.uired5 and such dis.uali*ication shall be *or such number o* days as may be decided by the authority authorised by the Corporation in this behal*G P#"4%*'* that a )oman may re*use to be e(amined by other than a *emale doctor or mid)i*e. A5$!"#%$3 0!%1! /(3 %..5' 1'#$%-%1($', $2. =o certi*icate re.uired under any o* the regulations 3I to 3$H shall be issued e(cept by the Insurance ?edical 7**icer to )hom the insured )oman has or had been allotted or by an Insurance ?edical 7**icer attached to a dispensary# hospital# clinic or other institution to )hich the insured )oman is or )as allotted and such Insurance ?edical 7**icer shall e(amine and i* in his opinion the condition o* the )oman so @usti*ies or in case o* death o* the insured )oman or the death o* the child# i* satis*ied about such death issue to such insured )oman or in case o* her death to her nominee or legal representati9e as the case may be# *ree o* charge any such certi*icate )hen reasonably re.uired by such insured )oman or her nominee or legal representati9e# as the case may be# under or *or the purposes o* the Act or any other enactment or these Regulations G P#"4%*'* that such 7**icer may issue a certi*icate# as a*oresaid# under these Regulations# to or in respect o* an insured )oman )ho is or )as not allotted to him or to the dispensary# hospital# clinic or other institution to )hich such o**icer is attached# i* such 7**icer is attending the )oman *or prenatal care# *or con*inement# *or miscarriage or *or sic8ness arising out o* pregnancy# con*inement# premature birth o* child or miscarriage or in case o* death# )as attending the deceased insured )oman or the child at the time o* death o* the insured )oman or the childG P#"4%*'* -5#$!'# that a certi*icate o* pregnancy# o* e(pected con*inement# or con*inement or miscarriage re.uired under these Regulations may be issued by a registered mid)i*e )hich shall be accepted by the Corporation on counterAsignatures by the Insurance ?edical 7**icerG P#"4%*'* that such o**icer may issue a certi*icate o* pregnancy# e(pected con*inement or con*inement under these regulations to an insured )oman )ho is not allotted to him or to the dispensary# hospital# clinic or other institution to )hich such o**icer is attached# i* such o**icer is attending the )oman *or prenatal care or *or con*inementG P#"4%*'* -5#$!'# that a certi*icate o* pregnancy# o* e(pected con*inement or o* con*inement re.uired under these regulations may be issued by a registered mid)i*e

)hich shall be accepted by the Corporation on counter signature by the Insurance ?edical 7**icer. O6&%7($%"). "- I).5#()1' M'*%1(& O--%1'#, $%. =othing in these regulations shall relie9e an Insurance ?edical 7**icer to )hom an insured )oman has been allotted# or an Insurance ?edical 7**icer attached to the dispensary# hospital# clinic or other institution to )hich an insured )oman is allotted o* the obligation to e(amine and i* in her opinion the condition o* the )oman so @usti*ies# issue *ree o* charge a certi*icate o* emergency# o* e(pected con*inement# or con*inement or miscarriage or o* sic8ness arising out o* pregnancy# con*inement# premature birth o* a child or miscarriage during any period in )hich such insured )oman is obtaining treatment or attendance *rom any other person or *rom any other hospital or institution. $2:?EDICAB HE=E>IT T7 >A?IBIE!< M'*%1(& 6')'-%$ $" -(/%&%'. "- %).5#'* 2'#.")., $%A. (1) ?edical bene*it may be e(tended to the *amilies o* insured persons *rom such date as the Corporation may# in consultation )ith !tate "o9ernment# noti*y. (') The *amily o* an insured person shall become entitled to medical bene*it $%:*rom the day the insured person himsel*< becomes entitled to medical bene*it and shall continue to be so entitled so long as the insured person is entitled to recei9e medical bene*it *or himsel* $C:or in the case o* death o* the insured person till such date up to )hich the insured person )ould ha9e remained entitled to medical care# had he sur9i9ed<. (4) The nature and scale o* medical bene*it to )hich the *amily o* an insured person shall be entitled shall be such as may be speci*ied by the !tate "o9ernment in consultation )ith the Corporation *rom time to time. $I:(2) The appropriate o**ice shall arrange to add in >orm 2# the particulars o* the *amily entitled to medical bene*it.< (%) $3:;;;< >+=ERAB $$:EPPE=!E!< R'2"#$ "- *'($! "- %).5#'* 2'#."), $%H. In case o* death o* an insured person/ (a) i* the death occurs at the place o* employment# the employer shall# and (b) i* the death occurs at any other place# the person entitled and intending to claim *uneral 1:e(penses< shall# or (c) any other person present at the time o* death may# immediately report the death to the %%a[,ranch 7**ice o* the deceased insured person.

I..5' "- *'($! 1'#$%-%1($', $%C. An Insurance ?edical 7**icer attending the insured person at the time o* death or the Insurance ?edical 7**icer )ho e(amines the body a*ter the death or the ?edical 7**icer )ho attended the insured person in a hospital or other institution )here such insured person died# shall issue *ree o* charge a death certi*icate in >orm 1a[1" to the person entitled and intending to claim *uneral 1:e(penses<. O$!'# '4%*')1' %) &%'5 "- ( 1'#$%-%1($', $%D. The Corporation may accept any other e9idence in lieu o* a death certi*icate by Insurance ?edical 7**icer i* in its opinion# the circumstances o* any particular case so @usti*y. S56/%..%") "- 1&(%/ -"# -5)'#(& 1['+2').'. , $%E. (1) A claim to *uneral 1:e(penses< shall be submitted to the appropriate %%a[,ranch 7**ice by post or other)ise in >orm 1b[77 by the claimant entitled under the Act and in case o* a minor# by his guardian# and such claim shall be supported by documents pro9ingG/ (i) the death o* the deceased person# (ii) that the person claiming is the eldest sur9i9ing member o* the *amily o* the deceased insured person and incurred the e(penditure necessary *or the *uneral o* the deceased# or (iii) in case the claimant is other than the eldest sur9i9ing member o* the *amilyG/ (a) that the deceased insured person did not ha9e a *amily or that the deceased insured person )as not li9ing )ith his *amily at the time o* his death5 and (b) that the claimant actually incurred the e(penditure claimed on the *uneral o* the deceased insured person G P#"4%*'* that )here the appropriate o**ice is satis*ied about the bona fides o* the applicant or about the truth o* the *acts relating to any o* the matters mentioned abo9e# one or more o* the documents may be dispensed )ith. (') The *ollo)ing may be accepted as proo* *or purposes o* clauses (ii) and (iii) o* subA regulation (1) o* this regulation/ A declaration o* the claimant duly countersigned by/ (i) an o**icer o* the Re9enue# ,udicial or ?agisterial Departments o* "o9ernment5 or (ii) a ?unicipal Commissioner5 or (iii) a For8men s Compensation Commissioner5 or (i') the Head o* "ram Panchayat under the o**icial seal o* the Panchayat5 or (') the employers o* the deceased insured person5 or ('i) any other e9idence or declaration acceptable to the appropriate o**ice in the circumstances o* a particular case.

CHAPTER I6 MISCELLANEOUS A5$!"#%$3 -"# *'$'#/%)%)7 6')'-%$., $C. The authority *or determining *or purposes o* subAsection (') o* section I& o* the Act# the 9alue o* bene*its other than cash payment shall be the ?edical Commissioner o* the Corporation. '[R'%/65#.'/')$ "- '+2').'. %)15##'* %) #'.2'1$ "- M'*%1(& $#'($/')$, $CA. Claims *or reimbursement o* e(penses incurred in respect o* medical treatment o* insured person and ()here such medical bene*it is e(tended to his *amily) his *amily may be accepted in circumstances and sub@ect to such conditions as the Corporation may by general or special order speci*y.< D%.1")$%)5($%") "# #'*51$%") "- 6')'-%$., $I. An employer may discontinue or reduce bene*its payable to his employees under conditions o* their ser9ice )hich are similar to the bene*its con*erred by the Act to the e(tent speci*ied belo)# namely/ (a) *rom the date o* the commencement o* the *irst bene*it period *ollo)ing the appointed day *or his *actory or establishment/ (i) sic8 lea9e on hal* pay to the *ull e(tent5 (ii) such proportion o* any combined general purposes and sic8 lea9e on hal* pay as may be assigned as sic8 lea9e but in any case not e(ceeding %& per cent o* such combined lea9e5 (b) any maternity bene*its granted to )omen employees to the e(tent to )hich such )omen employees may become entitled to the maternity bene*it under the ActG P#"4%*'* that )here an employee a9ails himsel* o* any lea9e *rom the employer *or sic8ness# maternity or temporary disablement# the employer shall be entitled to deduct *rom the lea9e salary o* the employee the amount o* bene*it to )hich he may be entitled under the Act *or the corresponding period. D%.1!(#7', '$1,, "- '/2&"3'' 5)*'# 1'#$(%) 1")*%$%")., $3. I* the conditions o* ser9ice o* any employee so allo)# an employer may discharge or reduce on due notice an employee/ (i) )ho has been in receipt o* disablement bene*it *or temporary disablement# a*ter he has been in receipt o* such bene*it *or a continuous period o* si( months or more5 (ii) )ho has been under medical treatment *or sic8ness or has been absent *rom )or8 as a result o* illness 4:;;;< duly certi*ied in accordance )ith these regulations to arise out o* the pregnancy or con*inement rendering the employee un*it *or )or8# a*ter the

employee has been under such treatment or has been absent *rom )or8 *or a continuous period o* si( months or more5 2:(iii) )ho has been under medical treatment *or any o* the *ollo)ing diseases# duly certi*ied in accordance )ith these regulations# a*ter the employee has been under such treatment *or a continuous period o* 13 months or more# not)ithstanding pro9isions o* clauses (i) and (ii)G DE!EA!E! %AI:I. In*ectious Diseases 1. Tuberculosis '. Beprosy 4. Chronic Empyema 2. Hronchiactesis %. Interstitial Bung Disease C. AID! II. =eoplasms I. ?alignant Diseases III. Endocrine =utritional and ?etabolic Disorders 3. Diabetes mellitus )ith proli*erati9e retinopathyKdiebetic *ootKnephropathy I6. Disorders o* =er9ous !ystem $. ?onoplegia 1&. Hemiplegia 11. Paraplegia 1'. Hemiparesis 14. Intracranial !pace 7ccupying Besion 12. Par8inson s disease 1%. !pinal Cord Compression 1C. ?yaesthenia "ra9isK=euromuscular Dystrophies 6. Diseases o* Eye 1I. Immature Cataract )ith 9ision CKC or less 13. Detachment o* Retina 1$. "laucoma 6I. Diseases o* Cardio9ascular !ystem '&. Coronary Artery Disease (a) +nstable Angina (b) ?yocardial in*raction )ith e@ection less than 2% per cent '1. Congesti9e Heart >ailureG Be*t

Right ''. Cardiac 6al9ular Diseases )ith *ailureKcomplications '4. Cardiomyopathies '2. Heart Disease )ith !urgical Inter9ention along )ith complications 6II. Chest Diseases '%. Chronic 7bstructi9e Bung Disease (C7PD) )ith congesti9e heart *ailure (Cor Pulmonale) 6III.Diseases o* the Digesti9e !ystem 'C. Cirrhosis o* li9er )ith ascitiesKchronic acti9e hepatitis IP. 7rthopaedic Diseases 'I. Dislocation o* 9ertebraKprolapse o* inter9ertebral disc '3. =onAunion or delayed union o* *racture '$. Post Traumatic !urgical amputation o* lo)er e(tremity 4&. Compound *racture )ith chronic osteomyelitis P. Psychoses 41. !ubAgroups under this are listed *or clari*ication (a) !chiLophrenia (b) Endogenous depression (c) ?anic Depressi9e psychosis (?D>) (d) Dementia PI. 7thers 4'. ?ore than '& per cent burns )ith in*ectionKcomplication 44. Chronic Renal >ailure. 42. Reynaud s diseaseKHurger s disease.< S5.2').%") "- .%1;)'.. "# $'/2"#(#3 *%.(6&'/')$ 6')'-%$, $$. !ic8ness bene*it o* disablement bene*it *or temporary disablement may be suspended# i* a person )ho is in receipt o* such bene*it *ails to comply )ith any o* the re.uirements o* section C2 o* the Act# and such suspension shall be *or such number o* days as may be decided by the authority authorised by the DirectorA"eneral in this behal*. 3[S%1;)'.. "# $'/2"#(#3 *%.(6&'/')$ 6')'-%$ *5#%)7 .$#%;', $$A. =o person shall be entitled to sic8ness bene*it or disablement bene*it *or temporary disablement on any day on )hich he remains on stri8e e(cept in the *ollo)ing circumstancesG/ (i) i* a person is recei9ing medical treatment and attendance as an indoor patient in any Employees !tate Insurance Hospital or a hospital recognised by the Employees !tate Insurance Corporation *or such treatment5 or

(ii) i* a person is entitled to recei9e e(tended sic8ness bene*it *or any o* the diseases *or )hich such bene*it is admissible5 or (iii) i* a person is in receipt o* sic8ness bene*it or disablement bene*it *or temporary disablement immediately preceding the date o* commencement o* notice o* the stri8e gi9en by the employees +nion(s) to the management o* the *actoryKestablishment5 or $:(i') i* an insured personKinsured )oman has undergone operation on account o* 9asectomyKtubectomy# heKshe shall be entitled to enhanced sic8ness bene*it on any day on )hich heKshe remains on lea9e during the period o* stri8e or remains on lea9e# or on holiday *or )hich heKshe recei9es )ages.< R'&(+($%"), 1&&. The DirectorA"eneral may by special or general order rela( any regulation under such circumstances and sub@ect to such conditions# as he may deem *it. 1&1. :;;;< C'#$(%) "--%1'#. $" !(4' 2"0'#. "- %).2'1$%"), 1&'. The DirectorA"eneral# the Insurance Commissioner# the ,oint Insurance Commissioner# a Deputy Insurance Commissioner# a Regional Director# a Deputy Regional Director# 1&:an Assistant Insurance Commissioner# an Assistant Regional Director< and a 1&a[,ranch 7**ice ?anager shall ha9e all the po)ers o* an Inspector speci*ied in subAsection (') o* section 2% o* the Act. In addition to the o**icers mentioned abo9e# the DirectorA"eneral may# by a )ritten order# con*er upon any employee o* the Corporation or any "o9ernment o**icer the po)ers o* an Inspector *or such period or periods as he may thin8 *it. 11[I).2'1$%") 6"";, 1&'A. (i) E9ery principal employer shall maintain a bound inspection boo8 and shall be responsible *or its production# on demand by an Inspector or any other 7**icer o* the Corporation duly authorised to e(ercise the po)ers o* an Inspector irrespecti9e o* the *act )hether the principal employer is present in the *actory or establishment or not during the inspection. (ii) A note o* all irregularities and illegalities disco9ered at the time o* inspection indicating therein the action# i* any# proposed to be ta8en against the principal employer together )ith the orders *or their remedy or remo9al passed by an Inspector or any other o**icer o* the Corporation duly authorised to e(ercise the po)ers o* an Inspector# shall be sent to the principal employer )ho shall enter the note and orders in the inspection boo8. (iii) E9ery principal employer shall preser9e the inspection boo8 maintained under this regulation# a*ter it is *illed *or a period o* % years *rom the date o* the last entry therein.<

M'*%1(& 6')'-%$ *5#%)7 *%.(6&'/')$, 1&4. A person )ho is in receipt o* disablement bene*it shall be entitled to medical bene*it )hile he is in receipt o* such bene*itG P#"4%*'* that a*ter the disablement has been declared as a permanent disablement# the person shall not be entitled to medical bene*it# i* he is not other)ise entitled to such bene*it# e(cept# in respect o* any medical treatment )hich may be rendered necessary on account o* the employment in@ury *rom )hich the disablement resulted. 1'[M'*%1(& 6')'-%$ (-$'# 1")$#%65$%") 1'(.'. $" 6' 2(3(6&', 1&4A. (1) A person on becoming an insured person *or the *irst time shall be entitled to medical bene*it *or a period o* 14:4 months< pro9ided that )here such a person continues *or 14:4 months< or more to be an employee o* a *actory or establishment to )hich the Act applies# he shall be entitled to medical bene*it till the beginning o* the corresponding bene*it period. 12:(') The person in respect o* )hom contributions ha9e been paid in a contribution period *or not less than se9entyAeight days in the said contribution period shall be entitled to medical bene*it till the end o* the corresponding bene*it periodG P#"4%*'* that in case o* a person )ho becomes an employee )ithin the meaning o* the Act# *or the *irst time# and *or )hom a shorter contribution period o* less than 1%C days is a9ailable# he shall be entitled to medical bene*it till the end o* the corresponding bene*it period i* the contributions in respect o* him )ere payable *or not less than hal* the number o* days a9ailable *or )or8ing in such contribution period G P#"4%*'* -5#$!'# that )here a person su**ering *rom any o* the *ollo)ing diseases# be*ore the commencement o* the spell o* sic8ness in )hich any such disease )as diagnosed being in continuous ser9ice *or a period o* t)o years or more or )here he did not ha9e t)o years continuous ser9ice but by 9irtue o* rela(ation granted by the authority competent in this behal*# the insured person .uali*ies to claim e(tended sic8ness bene*it# he shall be entitled to medical bene*it till the end o* the rele9ant e(tended bene*it periodG 12a:I. In*ectious Diseases 1. Tuberculosis '. Beprosy 4. Chronic Empyema 2. Hronchiactesis %. Interstitial Bung Disease C. AID! II. =eoplasms I. ?alignant Diseases III. Endocrine =utritional and ?etabolic Disorders 3. Diabetes mellitus )ith proli*erati9e retinopathyKdiebetic *ootKnephropathy I6. Disorders o* =er9ous !ystem

$. ?onoplegia 1&. Hemiplegia 11. Paraplegia 1'. Hemiparesis 14. Intracranial !pace 7ccupying Besion 12. Par8inson s disease 1%. !pinal Cord Compression 1C. ?yaesthenia "ra9isK=euromuscular Dystrophies 6. Diseases o* Eye 1I. Immature Cataract )ith 9ision CKC or less 13. Detachment o* Retina 1$. "laucoma 6I. Diseases o* Cardio9ascular !ystem '&. Coronary Artery Disease (a) +nstable Angina (b) ?yocardial in*raction )ith e@ection less than 2% per cent '1. Congesti9e Heart >ailureG Be*t Right ''. Cardiac 6al9ular Diseases )ith *ailureKcomplications '4. Cardiomyopathies '2. Heart Disease )ith !urgical Inter9ention along )ith complications 6II. Chest Diseases '%. Chronic 7bstructi9e Bung Disease (C7PD) )ith congesti9e heart *ailure (Cor Pulmonale) 6III.Diseases o* the Digesti9e !ystem 'C. Cirrhosis o* li9er )ith ascitiesKchronic acti9e hepatitis IP. 7rthopaedic Diseases 'I. Dislocation o* 9ertebraKprolapse o* inter9ertebral disc '3. =onAunion or delayed union o* *racture '$. Post Traumatic !urgical amputation o* lo)er e(tremity 4&. Compound *racture )ith chronic osteomyelitis P. Psychoses 41. !ubAgroups under this are listed *or clari*ication (a) !chiLophrenia (b) Endogenous depression

(c) ?anic Depressi9e psychosis (?D>) (d) Dementia PI. 7thers 4'. ?ore than '& per cent burns )ith in*ectionKcomplication 44. Chronic Renal >ailure. 42. Reynaud s diseaseKHurger s disease.< 1%:(4) An insured person# )hose title to medical bene*it has ceased under this regulation shall again be entitled to medical bene*it *rom the date o* his reAemployment as an employee under the Act by a *actory or establishment to )hich the Act applies# i* he produces a certi*icate *rom the employer in the *orm )hich may be speci*ied by the DirectorA"eneral *or the purpose. !uch an insured person shall# unless he is co9ered by subAregulation (')# be entitled to medical bene*it till the commencement o* the bene*it period corresponding to the contribution period in )hich he is reAemployed. 1C:(2)< An employer shall# on demand# issue the certi*icate re*erred to in 1I:subA regulation (4)< to an employee )ho has been employed by him a*ter cessation o* his pre9ious insurable employment.< 13[M'*%1(& 6')'-%$ $" %).5#'* 2'#.") 0!" 1'(.'. $" 6' %) %).5#(6&' '/2&"3/')$ ") (11"5)$ "- 2'#/()')$ *%.(6&'/')$, 1&4H. (1) An insured person )ho ceases to be in insurable employment on account o* permanent disablement caused due to employment in@ury shall continue to recei9e medical bene*it *or himsel* and hisKher spouse till the date on )hich he )ould ha9e 9acated the employment on attaining the age o* superannuation had he not sustained such permanent disablement# i* he produces a certi*icate *rom the employerKa declaration in the *orm )hich may be speci*ied by the DirectorA"eneral *or the purpose. (') <edical benefit to retired insured persons A An insured person )ho has attained the age o* superannuation shall be eligible to recei9e medical bene*it *or himsel* and hisKher spouse# i* he produces a certi*icate *rom the employer in the *orm )hich may be speci*ied by the DirectorA"eneral *or the purpose. (4) An employer shall# on demand# issue the certi*icate as re*erred to in subAregulations (1) and (') to an employee )ho had been employed by him.< P#"*51$%") "- *"15/')$ -"# /'*%1(& 6')'-%$, 1&2. A person intending to claim medical bene*it# and )ho is other)ise entitled to such bene*it# shall produce his Identity Card or such other document as may ha9e been issued in lieu thereo* at the time o* claiming such bene*it i* demanded by the Insurance ?edical 7**icer and i* he *ails to do so medical bene*it may be re*used to him. :5#$!'# 1'#$%-%1($'., 1&%. Fhere any .uestion arises as to the correctness o* any certi*icate by 9irtue o* )hich an insured person claims# or is entitled to# any bene*it under the Acts# he shall# on being

so re.uired in )riting or other)ise by the appropriate o**ice submit himsel*# )ith a 9ie) to obtaining a *urther certi*icate# to medical e(amination by such medical authority as the Corporation may appoint in this behal*. 1$:I* the *urther certi*icate speci*ies the date on )hich the insured person is or )ill be *it to resume )or8# any certi*icate )hich is or has been issued by the Insurance ?edical 7**icer *or the same spell o* incapacity shall# to the e(tent to )hich it relates to any period a*ter and including the said date on the *urther certi*icate# be deemed not to ha9e been issued in accordance )ith these Regulations and such *urther certi*icate shall# not)ithstanding anything contained in these regulations# be deemed to be a *inal certi*icate issued under regulations %3 and C&.< =ot)ithstanding anything contained in these Regulations# such *urther certi*icate inso*ar as it relates to sic8ness or temporary disablement# may be issued at such inter9al and in respect o* such periods as may be speci*ied by such medical authority. C!()7' "- 1%#15/.$()1'. $" 6' )"$%-%'*, 1&C. E9ery person to )hom any bene*it is payable under the Act shall# as soon as may be practicable# noti*y the appropriate o**ice o* any change o* circumstance )hich he may be e(pected to 8no) and )hich might a**ect the continuance o* his right to receipt o* such bene*it. '&[C'#$%-%1($' %) #'.2'1$ "- ( 2'#.") 1&(%/%)7 2'#/()')$ *%.(6&'/')$ 6')'-%$, 1&I. E9ery person )hose claim *or any permanent disablement bene*it has been admitted shall submit at si(Amonthly inter9als# )ith the claim *or December and ,une e9ery year# a certi*icate in >orm '&a[7" attested by such authority or persons and in such manner as may be speci*ied by the DirectorA"eneral. '1[D'1&(#($%") 63 ()* 1'#$%-%1($' %) #'.2'1$ "- ( 2'#.") 1&(%/%)7 *'2')*()$. 6')'-%$, 1&IA. E9ery person )hose claim *or any dependants bene*it has been admitted shall submit at si( monthly inter9als# )ith the claim *or December and ,une e9ery year# a declaration and a certi*icate in >orm '1a[7" attested by such authority or person and in such manner as may be speci*ied by the DirectorA"eneral. P'#.")(& ($$')*()1' "- ( 2'#.") 1&(%/%)7 2'#/()')$ *%.(6&'/')$ 6')'-%$ "# *'2')*')$. 6')'-%$, 1&IH. In the case o* claimant *or permanent disablement bene*it or dependants bene*it# the appropriate 1&a[,ranch ?anager may re.uire personal attendance and due identi*ication o* any claimant# other than a person incapacitated by bodily illness or in*irmity or a purdanashin lady at the appropriate '1b[,ranch 7**ice or at any other o**ice o* the Corporation pro9ided that such appearance shall not be re.uired more *re.uently than once in e9ery si( months.<

A1$5(#%(& 2#'.')$ 4(&5' "- $!' 2'#%"*%1(& 2(3/')$., 1&3. '':; ; ;< '4:S56/%..%") "- (**%$%")(& %)-"#/($%") 63 '/2&"3'# "# %).5#'* 2'#."), 1&$. The employer or insured person# as the case may be# shall# on demand *rom the appropriate o**ice# submit in*ormation in such *orm as may be speci*ied by the DirectorA "eneral.<

>4:ORM 01 :See Regulation 1&H< E?PB7EER!Q RE"I!TRATI7= >7R? (Regulation 1&AH) ;EmployerQs Code =o. 1. =ame o* the >actoryKEstablishment G ................................................................................. '. Complete postal address o* the >actoryK G ................................................................................. Establishment .....................................PI=...................................... ................................................................................. 4. (a) Telephone =o.# i* (b) >a( =o i* any ................................................... any............................ (c) EAmail address# i* any........................................ (d) =ame o* To)nKRe9enue 6illage......................... (Talu8KTahsil) .................................................. (e) Police !tation.................................................... (f) Re9enue DemarcationKHudbast =o. ................... 2. Bocation o* >actoryKEstablishment (a) !tate................................................. .. (b) District............................................. .. ( c) ?unicipalityKFard.......................... ..... %. (a) Fhether the buildingKpremises o* G ................................................................................. *actoryKestablishment is o)ned or hired (b) I* hired or there is a change in the name o* unitKo)nership# please indicateG/ (i) E!I Code =o.# i* co9ered earlier (ii) Date *rom )hich earlier *actoryK establishment closed do)n (iii) Terms and conditions under )hich property ac.uiredKta8en on lease ................................................................................. ................................................................................. G

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

(Enclose copy agreementKrele9ant deed) C. (a) Details o* Han8 AKcG (a) Account =o. ............................... (b) Account =o. ............................... (c) Account =o. ............................... I. (a) Income Ta( PA=K"IR =o. (b) Income Ta( FardKCircleKArea

o* G (b) =ame o* Han8 and Hranch (i) .................................................................. (ii) .................................................................. (iii) ..................................................................

G ................................................................................. .................................................................................

3. E(act nature o* )or8Kbusiness carried on G ................................................................................. $. Date o* commencement o* >actoryK G ................................................................................. Establishment 1& (a) Fhether registered under G ................................................................................. . >actoriesK!hop and EstablishmentK7ther Act (Please speci*y) (b) >actory Bicence =o.KTrade Bicence G Bicence =o. =o.K Catering Establishment Bicence =o.K!hop Establishment Registration =o.KBicence =o. under Cinematography Act etc. (c) Please gi9e )hiche9er is applicable G =o. (i) Commercial Ta( =o. (ii) !tate !ales Ta( =o. (iii) Central !ales Ta( =o. (i') Any other Ta( =o. (i) (ii) (iii) (i') Date Bicencing Authority

Date

Issuing Authority

(d) ?a(imum number o* persons that G ................................................................................. can be employed on any one day# as per licence 11 . (a) Fhether po)er is used *or G ................................................................................. manu*acturing process as per !ection '(-) o* the >actory Act. I* so# since )hen (b) In case o* *actory )hether licence G ................................................................................. issued under !ection '(m)(i) or '(m)(ii) o* the >actories Act# 1$23 !anctioned Issuing Authority po)er load (a) Fhether it is Public or Pri9ate. Btd. G ................................................................................. CompanyKPartnershipKProprietorshi pKCoAoperati9e !ocietyK7)nership (Attach copy o* ?emorandum and Articles o* AssociationKPartnership (c) Po)er connection =o. =o.

1' .

DeedKResolution) =ame Designation Address (i) (ii) (iii) (i') ( ') ('i) ('ii) 14 Address(es) o* the Registered G Address =o. o* Phone >unction Person . 7**iceKHead 7**iceK Hranch 7**iceK!ales as on employee =o.K >a( responsible 7**iceKAdministrati9e 7**iceK other date =o. *or dayAtoA o**ices# i* any# )ith number o* day employees attached )ith each such *unctioning o**ice and person responsible *or the o* the o**ice o**ice ("i9e details on a separate sheet# i* re.uired) 12 (a) Fhether any )or8Kbusiness carried G ................................................................................. . out through contractorKimmediate employer (b) I* yes# gi9e )or8Kbusiness 1% . (a) EP> Code =o. (I* co9ered under EP> Act) 1C. Total number o* employees employed *or )ages directly and through immediate employers on the date o* application (Fhether manualKclericalKsuper9isor# connected )ith the administration or purchase o* ra) materials or distribution or sale o* productKser9ice# )hether permanent or temporary) As on date Total =o. o* employees ?ale Employed directly by the Principal Employer Through Immediate employerK Contractor Total 1I. Total )ages paid in the preceding month Total )ages Fages paid to employees dra)ing )ages Rs I%&& or less >emale Total =o. o* employees dra)ing )ages Rs I%&& or less ?ale >emale Total nature o* such G ................................................................................. G =o. Issuing Authority (b) "i9e name# present and permanent residential address o* present ProprietorK?anaging Directors# DirectorK?anaging Partners# PartnersK!ecretary o* the CoA operati9e !ociety.

To employees employed directly by the Principal employer To employees employed through immediate

employerKContractor 13. "i9e *irst date since )hen 1&K'&;; or more ................................................................................ co9erable employees under E!I Act )ere employed *or )ages I hereby declare that the statement gi9en abo9e is correct to the best o* my 8no)ledge and belie*. I also underta8e to intimate changes# i* any# promptly to the Regional 7**iceK!ubARegional 7**ice. E!I Corporation is soon as such changes ta8e place D($' =ame and !ignature..................................... Place Designation )ith seal............................................ :!hould be signed by principal employer uKs. '(1I) o* E!I Act<

; Please mention the EmployerQs Code =o. i* pre9iously allotted in case the *actoryKestablishment )as co9ered under the E!I Act. ;; !core out )hiche9er is not applicable. In case o* *actoryKan establishment using po)er in the manu*acturing process the number applicable is 1& persons or more. In the case o* a *actory not using po)er or an establishment engaged in manu*acturing process )ithout using po)er or any other establishment# the number applicable is '& or more persons. I=S13>$1I4=S =ote 12/Please enclose photocopy o* the *ollo)ing deedsKagreementsKdocumentsKcerti*icateG (a) Registration Certi*icateKBicence issued under !hops and Establishments Act or >actories Act. (b) Batest Rent Hill o* the premises you are occupying indicating the capacity in )hich the premises is occupied# i* applicable. (c) Batest Huilding Ta(KProperty Ta( receipt (Rero(). (d) ?emorandum and Articles o* AssociationKPartnership DeedKTrust Deed. (e) Rero( copy o* certi*icate o* commencement o* production andKor Registration =o. o* C!TK!T. =ote 72/SPo)erS shall ha9e the meaning assigned to it in the >actories Act# 1$23 )hich is as underG/ QPo)erQ means electrical energy# or any other *orm o* energy )hich is mechanically transmitted and is not generated by human or animal agency. =ote "2/?anu*acturing process as de*ined in !ection 7(%) in >actories Act is as underG/ ?<anufacturin& process? means any process for+ (i) ma8ing# altering# repairing# ornamenting# *inishing# pac8ing# oiling# )ashing# cleaning# brea8ing up# demolishing# or other)ise treating or adapting any article or substance )ith a 9ie) to its use# sale# transport# deli9ery or disposal5 (ii) pumping oil# )ater# se)age or any other substance5 (iii) generating# trans*orming or transmitting po)er5 (i') composing types *or printing# printing by letter press# lithography photogra9ure or other similar process or boo8 binding5

(') constructing# reconstructing# repairing# re*itting# *inishing or brea8ing up ships or 9essels5 ('i) preser9ing or storing any article is cold storage. =ote 42/SImmediate EmployerS in relating to employees employed by or through him# means a person )ho has underta8en the e(ecution# on the premises o* the *actory or an establishment to )hich this Act applies or under the super9ision o* the principal employer or his agent# o* the )hole or any part o* any )or8 )hich is ordinarily part o* the )or8 o* the *actory or establishment o* the principal employer or is preliminary to the )or8 carried on in# or incidental to the purpose o*# any such *actory or establishment and includes a person by )hom the ser9ices o* an employee )ho has entered into a contract o* ser9ice )ith him are temporarily lent or let on hire to the principal employer and includes a contractor. =ote 82/SPrincipal EmployerS means/ (a) In a *actory the o)ner or occupier o* the *actory and includes the managing agent o* such o)ner or occupier# the legal representati9e o* a deceased o)ner or occupier and )here a person has been named as the manager o* the *actory under the >actories Act# 1$23# the person so named5 (b) In any establishment under the control o* any department o* any "o9ernment# in India the authority appointed by such "o9ernment in this behal* or )here no authority is so appointed# the head o* the Department5 (c) In any other establishment# any person responsible *or the super9ision and control o* the establishment. =ote ;2/S7ccupierS o* a *actoryKestablishment means the person )ho has ultimate control o9er the a**airs o* the *actoryKestablishment and )hen the said a**airs are entrusted to a managing agent shall be the occupier o* the *actoryKestablishment =ote I./SEmployeesS means any person employed *or )ages in or in connection )ith the )or8 o* a *actory or an establishment to )hich this Act applies# and (i) )ho is directly employed by the principal employer on any )or8 o*# or incidental or preliminary to or connected )ith the )or8 o*# the *actory or establishment )hether such )or8 is done by the employee in the *actory or establishment or else)here5 or (ii) )ho is employed by or through an immediate employer on the premises o* the *actory or establishment or under the super9ision o* the principal employer or his agent on )or8 )hich is ordinarily part o* the )or8 o* the *actory or establishment or )hich is preliminary to be carried on in or incidental to the purpose o* the *actory or establishment5 or (iii) )hose ser9ices are temporarily lent or let on hire to the principal employer by the person )ith )hom the person )hose ser9ices are so lent or let on hire has entered into a contact o* ser9ice5 and includes any person employed *or )ages on any )or8 connected )ith the administration o* the *actory or establishment or any part department or branch thereo* )ith the purchase o* ra) materials *or# or the distribution or sale o* the products o*# the *actory or establishment5 :or any person engaged as an apprentice# not being an apprentice engaged under the Apprentices Act# 1$C1 (%' o* 1$C1)# or under the standing

orders o* the establishment# but does not include</ (a) Any member o* the Indian =a9al# ?ilitary or Air >orce5 or (b) Any person so employed )hose )ages e(cluding remuneration *or o9ertime )or8 e(ceeds such )ages as may be prescribed by the Central "o9ernment# a monthG Pro9ided that an employee )hose )ages e(cluding remuneration *or o9ertime )or8 e(ceeds such )ages as may be prescribed by the Central "o9ernment# a month at any time a*ter and not be*ore the beginning o* the contribution period# shall continue to be an employee until the end o* that period. =ote 2/SFagesS means all remuneration paid or payable in cash to an employee# i* the terms o* the contract o* employment# e(press or implied# )ere *ul*illed and includes any payment to an employee in respect o* any period o* authoriLed lea9e# loc8Aout# stri8e )hich is not illegal or layAo** and other additional remuneration# i* any# paid at inter9als not e(ceeding t)o months# but does not includeG (a) any contribution paid by the employer to any pension *und or pro9ident *und# or under this Act5 (b) any tra9elling allo)ance or the 9alue o* any tra9elling concession5 (c) any sum paid to the person employed to de*ray special e(penses entailed on him by the nature o* his employment5 or (d) any gratuity payable on discharge.

'2a >7R?A&1(A) >7R? 7> A==+AB I=>7R?ATI7= 7= >ACT7REK E!TAHBI!H?E=T C76ERED +=DER E!I ACT (Regulation 1&AC) ;EmployerQs Code =o. 1. =ame o* the >actoryKEstablishment GTTTTTTTTTTTTTTTTTTTTTTTTTTT. '. Complete postal address o* theGTTTTTTTTTTTTTTTTTTTTTTTTTTT >actoryK Establishment TTTTTTTTTTTTTTT.PI=TTTTTTTTTT. 4. (a) Telephone =o.# i* anyTTTTT (b) >a( =o. i* anyTTTTTTTTTTTTTTTTTTTT. (c) EAmail address# i* anyTTTTTTTTTTTTTTTTT (d) =ame o* To)nKRe9enue 6illage TTTTTTTTT (Talu8KTahsil)TTTTTTTTTTTT (e) Police !tationTTTTTTTTTTTTTTTTTTT (f) Re9enue DemarcationKHudbast =oTTTTTTTTTTT 2. Bocation o* >actoryKEstablishment G (a) !tateTTTTTTTTTTT.. (b) DistrictTTTTTTTTTTT (c) ?unicipality K FardTTTTT %. (a) Details o* Han8 AKcG (a) Account =o (b) Account =o (c) Account =o C.(a) Income Ta( PA=K"IR =o. (b) Income Ta( FardKCircleKArea G(b) =ame o* Han8 and Hranch (i)TTTTTTTTTTTTTTTTTTTTTT.. (ii)TTTTTTTTTTTTTTTTTTTTT.... (iii)TTTTTTTTTTTTTTTTTTTTT.. GTTTTTTTTTTTTTTTTTTTTTTTT TTTTTTTTTTTTTTTTTTTTTTTT..

I. (a)In case o* *actory )hether licenceGTTTTTTTTTTTTTTTTTTTTTTTT... issued under section '(m)(i) or '(m)(ii) o* the >actories Act# 1$23 (b) Po)er Connection =o. =o. !anctioned po)er load Issuing Authority 3. (a)Fhether it is Public or Pri9ate Btd. GTTTTTTTTTTTTTTTTTTTTT... CompanyKPartnershipKProprietorshi pKCoAoperati9e !ocietyK7)nership (Attach copy o* ?emorandum and Articles o* AssociationKPartnership DeedKResolution) (b) "i9e name# present and permanent residential address o* present (i) ProprietorK ?anaging Directors# (ii) DirectorK?anaging Partners# (iii) PartnersK!ecretary o* the CoA (i') operati9e !ociety ( ') =ame Designation Address

('i) ('ii) $. Address(es) o* the Registered Address as 7**iceKHead 7**iceKHranch on date 7**iceK!ales 7**iceKAdministrati9e 7**iceKother o**ices# i* any# )ith number o* employees attached )ith each such o**ice and person responsible *or the o**ice

=o. o* employee

Phone >unction Person =o.K>a( =o. responsible *or dayAtoAday *unctioning o* the o**ice

"i9e details on a separate sheet# i* re.uired) 1&.(a) Fhether any )or8KbusinessGTTTTTTTTTTTTTTTTTTTTTTTT.. carried out through contractorKimmediate employer (b)I* yes# gi9e nature o* such GTTTTTTTTTTTTTTTTTTTTTTTT.. )or8Kbusiness I hereby declare that the statement gi9en abo9e is correct to the best o* my 8no)ledge and belie*. I also underta8e to intimate changes# i* any# promptly to the Regional 7**iceK!ubARegional 7**ice# E!I Corporation as soon as such changes ta8e place Date =ame and !ignatureTTTTTTTTTTTTT Place Designation )ith sealTTTTTTTTTTTTTTT. :!hould be signed by principal employer uKs. '(1I) o* E!I Act<

>5->7:ORM 1 DECLARATION :ORM To be *illed by employee a*ter reading instructions o9erlea*. T)o postcard siLe photographs to be attached )ith the *orm. The *orm is *ree o* cost. (A) I=!+RED PER!7=Q! PARTIC+BAR! (H) E?PB7EERQ! PARTIC+BAR!
1. Insurance =o. '. =ame (in bloc8 letters) 4. >atherQsKHusbandQs name 2. Date o* birth Day ?onth Eear %. ?arital !tatus C. !e( I. Present Address TTTTTTTTTTTTT. TTTTTTTTTTTTT. TTTTTTTTTTTTT. Pin code Telephone =o.KeAmail address Hranch 7**ice 3. Permanent Address TTTTTTTTTTTTT. TTTTTTTTTTTTT. TTTTTTTTTTTTT. Pin code Telephone =o.KeAmail address Dispensary Telephone =o.KeAmail address ?K+KF $. EmployerQs Code =o. 1&. Date o* Appointment Day ?onth Eear

11. =ame and Address o* the Employer TTTTTTTT TTTTTTTT ?K> TTTTTTTT 1'. In case o* any pre9ious employment please *ill up the details as underGA (a) Pre9ious Ins. =o. (b) EmployerQs Code =o. (c) =ame and Address o* Employer

(C). Details o* =ominee uKs. I1 o* E!I Act 1$23KRule %C(') o* E!I (Central) Rules# 1$%& *or payment o* cash bene*it in the e9ent o* death

=ame

Relationship

Address

I hereby declare that the particulars gi9en by me are correct to the best o* my 8no)ledge and belie*. I underta8e to intimate the Corporation any changes in the membership o* my *amily )ithin 1% days o* such change. CounterAsignature by the employer !ignatureKT.I# o* IP !ignature )ith seal (D) >A?IBE PARTIC+BAR! 7> I=!+RED PER!7= !l. =o. 1. '. 4. 2. %. C. I. E!I Corporation Temporary Identity Card =ame Ins. =o. Hranch 7**ice Date o* appointment Dispensary 6alid *or 4 months *orm the date o* appointment (!pace *or photograph) =ame Date o* HirthKAge as on date o* *illing *orm Relationship )ith the Employee Fhether residing )ith himKher. !ay Ees =o I* Q=oQ !tate place o* Residence To)n !tate

EmployeeQs Code =o. and Address 6alidity DatedG I=!TR+CTI7=! 1. !ubmission o* >ormA1 is go9erned by Regulations 11 and 1' o* E!I ("eneral) Regulations# 1$%&. '. S>amilyS means all or any o* the *ollo)ing relati9es o* an Insured Person# namelyGA (i) a spouse5 (ii) a minor legitimate or adopted child dependant upon the I.P.5 !iii# a child )ho is #)holly dependant on the earnings o* the I.P. and )ho is (a) recei9ing education# till he or she attains the age o* '1 years (b) an unmarried daughter5 (i9) a child )ho is in*irm by reason o* any physical or mental abnormality or in@ury and is )holly dependant on the earnings o* the I.P. so long as the in*irmity continues5 (9) dependant parents (Please see !ection ' Clause 11 o* the E!I Act# 1$23 *or details). 4. Identity Card is notATrans*erable. 2. Boss o* Identity Card be reported to EmployerKHranch ?anager immediately. %. !ubmission o* *alse in*ormation attracts penal action under !ection 32 o* E!I Act# 1$23. C. This *orm duly *illed in must reach the concerned Hranch 7**ice )ithin 1& days o* appointment o* an Employee. Delay attracts penal action under !ection 3% o* the Act against employer. I. As an insured person you and your dependent *amily members are entitled to *ull medical care *rom today itsel*. The other bene*its in cash include (a) !ic8ness Hene*it (') Temporary Disablement bene*it (4) Permanent disablement bene*it (2) Dependents bene*it and (%) ?aternity bene*it (in case o* )omen employees) sub@ect to *ul*illment o* contributory conditions. 3. >or more details please contact )ebsite o* E!IC at ))).esic.org.in or contact Regional 7**ice or Hranch 7**ice. >7R HRA=CH 7>>ICE +!E 7=BE 1. Date o* allotment o* Ins. =o.GTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT.. Date o* issue o* T.I.C. G GTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT.. !ignatureKT.I o* I.P. !ignature o* H.?. )ith seal

4. =ameK=o# o* Disp. G GTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT.. 2. Fhether reciprocal medical arrangements in9ol9ed. I* yes# please indicateG GTTTTTTTTTTTTTTTTTTTTTT.. !ignature o* Hranch ?anager !l. =o. 1. '. 4. 2. %. C. I. =ame Date o* HirthKAge as on date o* *iling *orm Relationship )ith the Employee Fhether residing )ith himKher. !ay Ees =o I* Q=oQ !tate place o* Residence To)n !tate

'3[:ORM 1A :3e&ulation 18A< :AMILY DECLARATION :ORM =ame o* the insured person .................................................................................................................... Insurance =umber ................................................................................................................................. .... Serial =o2 =ame 5ate of birth 3elationship with insured person 79@Ahether residin& with himBher or notC

I hereby declare that the particulars abo9e ha9e been gi9en by me and are true to the best o* my 8no)ledge and belie*. I also underta8e to intimate to the Corporation any changes in the membership o* my *amily )ithin 1% days o* such changes ha9ing occurred. Si&natureB1humb)impression of the insured person Date............... Countersigned .................................................. Date ....................................................................... Designation ........................................................ =ame# Address and Code =o. o* Employer ............................................................. 4&:=ote A According to section '# clause ( 11) o* the Employees !tate Insurance Act# 1$23# 0*amily1 means all or any o* the *ollo)ing relati9es o* an insured person# namely# (i) a spouse5 (ii) a minor legitimate or adopted child dependent upon the IP5 ( iii) a child )ho is )holly dependent on the earnings o* the IP and )ho is A ( a) recei9ing education# till he or she attains the age o* '1 years# (b) an unmarried daughter5 (i') a child )ho is in*irm by reason o* any physical or mental abnormality or in@ury and is )holly dependent on the earnings o* the IP# so long as the in*irmity continues5 (') dependent parents.< 41A4' RE". >7R?A' AdditionB5eletion in /amily 5eclaration /orm E?PB7EEE!Q !TATE I=!+RA=CE C7RP7RATI7= (Regulation 1%AH) =ame o* the Insured Person Insurance =o. I declare that the personKpersons )hose particulars are gi9en belo) hasKha9e no) becomeKceased to be member(s) o* my *amily.; !l. =ame Date Reason(s) =o. o* *or birth change Relationship )ith the Fhether residing )ith herK I* no# )here residing =ame o* I?PKDisp.

and date

Insured person

him or not# state Ees =o Distt. !tate

attached

I hereby declare that the particulars gi9en abo9e are true to the best o* my 8no)ledge and belie*. =ecessary changes may 8indly be made in my Declaration >orm submitted earlier. Passport siLe photographs o* the members )ho are added to *amily isKare enclosed. Place TTTTTTTTTTTTTTTTTTTTTT Date !ignatureKthumb impression o* the employee =ame in Hloc8 BettersTTTTTTTTT Particulars o* the EmployerG/ =ameGTTTTTTT..T TTTTT..T... AddressG TTTT TTTTTTTTTT.. TTTTTTTTTTTT TTTTTT. Code =oTTTTTTT.. TTTTT.TT. Countersignature o* the employer

TTTTTTTTTTTT. Designation )ith Rubber !tamp

=ote2/S>amilyS means all or any o* the *ollo)ing relati9es o* an Insured Person# namelyG/ (i) a spouse5 (ii) a minor legitimate or adopted child dependant upon the I.P.5 (iii) a child )ho is )holly dependant on the earnings o* the I.P. and )ho is (a) recei9ing education# till he or she attains the age o* '1 years (b) an unmarried daughter5 (i') a child )ho is in*irm by reason o* any physical or mental abnormality or in@ury and is )holly dependant on the earnings o* the I.P. so long as the in*irmity continues5 !'# dependant parents (Please see !ection '# Clause 11 o* the E!I Act# 1$23 *or details). ; Please submit duly attested copy o* the HirthKDeath Certi*icate.

:ORM > :3e&ulation 1"< CONTRI8UTION CARD 42:;;;< :ORM ? :3e&ulation 14< RETURN O: DECLARATION :ORMS =ame and address o* the >actory or Establishment .......................................................... Employer s Code =umber .......................................................... I send here)ith the Declaration >orms in respect o* the employees mentioned belo). I hereby declare that e9ery person employed as an employee )ithin the meaning o* section '(9) o* the Employees !tate Insurance Act# 1$23# on .......................in this *actory or establishment and in receipt o* a remuneration not e(ceeding 4%[3s2 7,800 (no) Rs. 4#&&&) per month has been included in this list (e(cepting only those in respect o* )hom declarations ha9e been sent to the Corporation in the past). 9lace....................... Si&nature.................................. 5ate........................ 5esi&nation.............................. !erial =o. =ame o* the Distinguishing =o. employee )ith the employer# i* any ' 4 >ather s or Husband s name 2 Insurance =o. allotted by the Corporation (to be entered at the Appropriate 7**ice) %

!ignature....................................... Designation................................... Enclosures*+ Declaration >orms .................................................................................................................................... ................ Continuation sheets ..................................................................................................................................... ............

4C::ORM 4 :3e&ulations 17 D 98A< IDENTITY CARD I=!+RA=CE =7. EP M !TAT+! =A?E >ATHER 7R H+!HA=D ! =A?E PRE!E=T ADDRE!! E?PB7EER ! C7DE =7. ER. HTH. !ET DATE 7> E=TRE B7CAB 7>>ICE DI!PE=!ARE IDE=TI>ICATI7= ?AR-! E?PB7E?E=T CHA="E! DATE C7DE =7. DATE C7DE =7.

PARTIC+BAR! 7> ?E?HER! 7> >A?IBE !. =A?E =7. DATE 7> HIRTH REBATI7=!HIP FITH I.P. IDE=TI>ICATI7= ?AR-! ATTE!TATI7= HE I.?.7.KI.?.P.

!ignature or Thumb Issued by< Impression o* the I.P. (i) I.P. )ill be printed in *ull. (ii) Higger column )ill be pro9ided *or identi*ication mar8s at the time o* printing.

?7::ORM 4A :3e&ulation 98A< :AMILY IDENTITY CARD Insurance =o. =ame o* insured person ................................................. !e( ............................................................................................ !on o*KDaughter o*KFi*e o* ........................................ Address .................................................................................... Dispensary ............................................................................. 9articulars of members of family Serial =o2 1 ' 4 2 % C Si&nature or thumb impression of the insured person2 Prepared by< =am e 5ate of birth 3elationship with the insured person Identification <ar%s

:ORM 5 :3e&ulation 77< RECEIPT :OR CONTRI8UTION CARD 43:; ; ;< 4$RE". >7R?A% ; Due Date *or submissionG/ 1'th ?ayK11th =o9ember; =ame o* Hranch EmployerQs Code 7**iceTTTTTTTTTTT =oTTTTTTT. 3eturn of $ontributions E<9E4FEES? S1A1E I=S>3A=$E $43943A1I4= (RegulationA'C) =ame and Address o* the *actory or G TTTTTTTTTTTTTTTTTTT. establishment Particulars o* the Principal Employer(s) (a) =ame G TTTTTTTTTTTTTTTTTTT. (b) Designation G TTTTTTTTTTTTTTTTTTT. (c) Residential Address G TTTTTTTTTTTTTTTTTTT. Contribution period *romTTTTTTTTTTTTtoTTTTTTTTTTTTT I *urnish belo) the details o* the employerQs and employeeQs share o* contributions in respect o* the undermentioned insured persons. I hereby declare that the return includes each and e9ery employee# employed directly or through an immediate employer or in connection )ith the )or8 o* the *actoryKestablishment or any )or8 connected )ith the administration o* the *actoryKestablishment or purchase o* ra) materials# sale or distribution o* *inished products etc. to )hom the E!I Act# 1$23 applies# in the contribution period to )hich this return relates and that the contributions in respect o* employerQs and employeeQs share ha9e been correctly paid in accordance )ith the pro9isions o* the Act and Regulations. EmployeesQ !hareTTTTTTTTTTTT.. EmployerQs !hareTTTTTTTTTTTT... Total ContributionTTTTTTTTTTTT.. Details o* ChallansG/ !I. =o. 1. '. 4. 2. %. M")$! Date o* Challan Amount =ame o* the Han8 and Hranch

C. P&(1' Total amount paidG Rs TTTTTTTT.. !ignature and Designation o* the Employer

@@@@@@@,, D($' @@@@@@@,,, (Fith Rubber !tamp) Important Instructions* In*ormation to be gi9en in SRemar8s Column (=o. $)S (i) I* any I.P. is appointed *or the *irst time andKor lea9es during the contribution period indicate SATTTT..(date)S andKor SBTTTTT(date)S (ii) Please indicate Insurance =os. in ascending order. (iii) >igures in Columns 2# % and C shall be in respect o* )age periods ended during the contribution period. (i') In9ariably stri8e totals o* Columns 2# % and C o* the Return. (') =o o9er)riting shall be made. Any corrections# i* made# should be signed by the employer. ('i) E9ery page o* this Return should bear *ull signature and rubber stamp o* the employer. ('ii) Daily )ages in Column I o* the return shall be calculated by di9iding *igures in Column % by *igures in Column 2 to t)o decimal places. >or ;CP ending 41st ?arch# due date is 1'th ?ay >or CP ending 4&th !eptember# due date is 11th =o9ember E<9E4FEES? S1A1E I=S>3A=$E $43943A1I4= EmployerQs =ame and Address EmployerQs Code =oTTTTTTTTTTT.. Period *romTTTTTTTTTTTT. toTTTTTTTTT. !I. Insuranc =o. e =umber 1 ' =ame o* Insured person 4 =o. o* days Total amount *or )hich o* )ages paid )ages paid (Rs) 2 % EmployeeQs contribution deducted (Rs) C A9erage Daily Fages (Rs) I Fhether still continues )or8ing 3 Remar8s;

T7TAB ;Date o* appointment and lea9ing the @ob may be gi9en in remar8s column !ignature o* the Employer (>7R 7>>ICIAB +!E) 1. Entitlement position mar8ed. '. Total o* Col. % o* Return chec8ed and *ound correctK correct amount is indicated. 4. Chec8ed the amount o* EmployerQsKEmployeeQs contribution paid )hich is in orderKobser9ation memo enclosed. Countersignat ure TTTTT TTTTT.. ,ranch 4fficer

>252$2

Gead $ler%

2&>7R? %AA EmployeesQ !tate Insurance Corporation (Regulation 41 / !econd Pro9iso) Statement of Ad'ance 9ayment of $ontributions made for the $ontribution 9eriod ended2222222222222222222222222222222222222222222222222222222222 Total contribution amounting to Rs..................... comprising o*................................ Rs................................ as employerQs share and Rs................................. as employeesQ share paid as underG/ !l. =o. 1 1. '. 4. 2. %. C. I. Details o* Ad9ance Payment ' Rs. 7pening Halance Challan dated ....................... Challan dated ....................... Challan dated ....................... Challan dated ....................... Challan dated ....................... Challan dated ....................... Total (i) Amount Details o* actual contribution paid 2 P. ;AprilK7ctober ....................... ....................... Amount Halance

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

....................... ;?ayK=o9ember ....................... ....................... ....................... ;,uneKDecember ....................... ....................... ....................... ;,ulyK,anuary ....................... .......................

....................... ;AugustK>ebruary ....................... ....................... ....................... ;!eptemberK?arch ....................... ....................... ....................... Total (ii) Total due *or contribution period Total amount paid in Ad9ance Halance

Total (ii) should not be less than total (i) at any time ;!tri8e out )hich is not applicable Place........................... Date...........................

!ignature........................... Designation...........................

21A2'RE". >7R?AC 3e&ister of Employees E?PB7EEE!Q !TATE I=!+RA=CE C7RP7RATI7= (Regulation 4') Contribution Period G >rom TTTTTTTTT toTTTTTTTTTTTT. ! Insura =a I. nce me = =o. o* o the . Insu red Pers on ;=am 7ccupat Depart e o* ion ment dispen and sary to shi*t# i* )hich any attach ed ?onthTTTTT.. I* appointed =o. Total Employ or le*t ser9ice o* amount eesQ during the days o* share o* contribution *or )ages contribu period# date )hi paidKpa tion o* ch yable appointmentKl )ag ea9ing es ser9ice paid K pay able C I 3 $

'

4(A)

Total Employe rQs share "rant total Paid on ?onth TTTTTTTTTT.. ?onth TTTTTTTTTT.. ?onth TTTTTTTTTT.. =o. o* days Total EmployeesQ =o. o* days Total EmployeesQ =o. o* days Total EmployeesQ *or )hich amount o* share o* *or )hich amount o* share o* *or )hich amount o* share o* )ages )ages contributio )ages )ages contributio )ages )ages contributio paidKpayab paidK n (Rs) paidKpayab paidK n (Rs) paidKpayab paidK n (Rs) le payable le payable le payable (Rs) (Rs) (Rs) 1& 11 1' 14 12 1% 1C 1I 13

Total EmployersQ share "rand

Total EmployersQ share "rand

Total EmployersQ share "rand

Total Paid on
?onth TTTTTTTTTT.. =o. o* Total Employe days *or amount esQ share )hich o* o* )ages )ages contribut paidKpay paidK ion (Rs) able payable (Rs)

Total Paid on
?onth TTTTTTTTTT.. =o. o* Total Employe days *or amount esQ share )hich o* o* )ages )ages contribut paidKpay paidK ion (Rs) able payable (Rs)

Total Paid on
!ummary TTTTTTTTTT.. Total =o. o* days *or )hich )ages paidKpay able in Contribu tion period '% Total amount o* )ages paidK payable in Contribu tion period (Rs) 'C Total Dail Employe y esQ share Fa o* ge Contribu ('%A tion in 'C) Contribu (Rs. tion ) period (Rs) 'I '3

1$

'&

'1

''

'4

'2

Total Employe rsQ share "rand Total Paid on

Total Employe rsQ share "rand Total Paid on

=ote2/ The *igures in Columns I to '2 shall be in respect o* )age periods ending in a particular calendar month.

24A2IRE". >7R?AI (Con*idential) (Deposit this certi*icate )ithin 4 days )ith the appropriate Hranch 7**ice to a9oid possible loss o* bene*it under Regulation C2) /irstBIntermediateB/inal $ertificate EmployeesQ !tate Insurance Corporation (Regulations %I# %3# %$) Hoo8 =oTTTTT.. !erial =oTTTTT. TTTTTTTTTTTTT.. !tamp o* Dispensary !ignature or Thumb impression o* the I.P. Date o* >irst Certi*icate o* EmployerQs Code spell o* !ic8ness or =oTTTTTT. DisablementTTTTT Hranch TTTT . 7**iceTTTTTTTTT. =ameTTTTTTTTTTTT..sK)KdTTTTTTTT.Ins. =oTTTTTTTTTTT.. Certi*ied that I ha9e e(amined you today and that in my opinionG/ Any other remar8s (i); by the ?edical 7**icer TTTTTTT. (ii); Eou no) need medical treatment# attendance and abstention *rom )or8 on medical grounds by reason o* (diagnosis) TTTTTTTTTTTT Eou ha9e continued to need medical treatment# attendance and abstention *rom )or8 on medical grounds up to and including this day by reason o* (diagnosis) TTTTTTT. TTTTTTTT... TTTTTTT. (iii); In my opinion you )ill be *it to resume )or8 tomorro)KonTTTTTTT

Attested by ?edical 7**icer =ote2/The date o* *itness must in no case be later than the third day a*ter the date o* the e(amination in case o* >irst and >inal Certi*icate DateTTTTTTTTT.. !ignatureTTTTTTTT Insurance ?edical 7**icer Rubber stamp =ame in Hloc8 BettersTTTTTTTTTTTTTTT. ; !tri8e out )hiche9er is not applicable Important*/ 1. Any person )ho ma8es *alse statement or representation *or the purpose o* obtaining bene*it )hether *or himsel*Ksome other person shall be punishable )ith imprisonment up to C months or *ine up to Rs '&&& or both.

'. This *orm should be completed and submitted )ithout delay to the appropriate Hranch 7**ice to escape penal deduction o* bene*it under Regulation C2 read )ith Regulation $$ o* E!I ("eneral) Regulations# 1$%&. 4. Insured person must sign# )ith date# the claim *orm to a9oid delay and incon9enience.

23A2$RE". >7R?A3 (Con*idential) (Deposit this certi*icate )ithin 4 days )ith the appropriate Hranch 7**ice to a9oid possible loss o* bene*it under Regulation C2) Special Intermediate $ertificate EmployeesQ !tate Insurance Corporation (Regulations C1 and 3$AH) Hoo8 =oTTTTT.. !erial =oTTTTT. TTTTTTTTTTTTT.. !tamp o* Dispensary !ignature or Thumb impression o* the I.P. Date o* >irst Certi*icate o* EmployerQs Code spell o* !ic8ness or =oTTTTTT. DisablementTTTTT Hranch TTTT . 7**iceTTTTTTTTT. ToTTTTTTTTTTTT..sK)KdTTTTTTTT.Ins. =oTTTTTTTTTTT.. Any other remar8s by the ?edical 7**icer TTTTTTTT.. TTTTTTTT.. TTTTTTTT.. Attestation by ?edical 7**icer Certi*ied that I ha9e e(amined you TTTTTTTTTTTTT.. today and that in my opinion you ha9e continued to need medical treatment and ha9e remained incapable to )or8 up to and including this day by reason o*TTTTTTTTTTT.I *urther certi*y that by @udging your present condition it is *ound that your sic8ness is o* such a character that it )ill be unnecessary to see you *or the purpose o* treatment more *re.uently than once in TTTTTTTTTTT )ee8s# and you )ill re.uire medical treatment and )ill remain incapable to )or8 at least up to the end o*TTTTTT.)ee8s *rom this dateTTTTTTTI propose to issue certi*icates in this *orm at the inter9al stated abo9e# so long as your condition does not re.uire more *re.uent attendance. In my opinion you should no)Kneed not be re*erred to a ?edical Hoard to determine i* you are permanently disabled

DateTTTTTT.. !ignatureTTTTTTTTTTTTTTTTTT Insurance ?edical 7**icer )ith rubber stamp =ame in bloc8 letters

%CRE". >7R?A$ $laim for Sic%nessB1252,2B<aternity ,enefit for Sic%ness EmployeesQ !tate Insurance Corporation (Regulations C4 and 3$AH) ITTTTTTTTTTTTTTT.Insurance =o TTTTTTTTTTTT..sK)Kd o*TTTTTTTTTTTTT. hereby claim Cash Hene*it *or period o9erlea* and state (i); That because o* sic8nessKtemporary disablementKsic8ness due to pregnancyKcon*inementKpremature birth o* childKmiscarriage# I ha9e not been at )or8 sinceTTTTTTTTTTTT (ii); I no longer claim to be sic8nessKtemporary disabledKsic8 due to pregnancyKcon*inementKpremature birth o* childKmiscarriage *rom TTTTTTTTTTTT. and I shallKdid not ta8e up any )or8 *or remuneration be*ore that date. (iii); I ha9e not been in receipt o* any )ages *or the days o* lea9eKholiday(s). (i'); I )as not on stri8e during the period o* certi*ied abstention on account o* sic8nessKtemporary disablement i.e. *romTTTTTTTTT toTTTTTTTTT..*or )hich the bene*it is claimed. I desire payment in ;cash at Hranch 7**iceKHy ?oney 7rder. !ignature or T.I o* Claimant =ame in Hloc8 BettersTTTTTT AddressTTTTTTTTTTTT.. HHHHHHHHHHHHHHHH2 =otes* 1. Any person )ho ma8es *alse statement or representation *or the purpose o* obtaining bene*it )hether *or himsel*Ksome other person shall be punishable )ith imprisonment up to C months or *ine up to Rs '&&& or both. '. This *orm should be completed and submitted )ithout delay to the appropriate Hranch 7**ice. 4. A *inal certi*icate must be obtained be*ore resuming )or8. ; !tri8e out i* not applicable.

ICAIIRE". >7R?A1&

(Con*idential) Abstention 6eri*ication in respect o* !ic8ness Hene*itK Temporary Disablement Hene*itK?aternity Hene*it Employees? State Insurance $orporation (Regulation %'AA) >romG The ?anager ...................................Hranch 7**ice E.!.I. Corporation# ToG ?Ks................................................. .......................................................... Sub-ect* 6eri*ication o* abstention *rom )or8 in respect o* !hriK!mtK-m........................................................... Ins. =o...........................Department............................................................ Dear !ir(s) The abo9e named employee o* your *actory has submitted a certi*icate o* incapacity *or the period *rom................................ to .......................... and has declared that heKshe has not )or8ed on any day during the abo9e period. HeK!he has *urther declared that heKshe has not recei9ed )ages as de*ined under section '('') o* E!I Act# 1$23 *or any lea9eKholidayK)ee8ly o**Klay o** and stri8e in respect o* any day during the abo9e period and that heKshe )as not on stri8e on any day during the abo9e period. I shall be grate*ul i* you con*irm the e(act position# in this regard# on the *orm# appended )ithin 1& days o* the receipt o* this *orm. Eours *aith*ully# ?anager ..................................Hranch 7**ice C7=>IDE=TIAB REPBE T7 HE >+R=I!HED HE THE E?PB7EER I= RE!PECT 7> >7R? =7. 1& =ame o* the Insured PersonKInsured Foman................................................................... Insurance =o. ............................................ Returned )ith the remar8s that the employee in .uestion has not )or8ed on any day during the period *rom ............................. to ........................ or; that heKshe has )or8ed on .................................. during the period *rom ................................. to ................................. It is *urther con*irmed that/ (a) HeK!he remained on lea9e )ith )ages *or the period *rom ............................. to ....................

(b) HeK!he remained on holidays )ith )ages *rom ......................... to ............................. (c) HeK!he )as on )ee8ly o** )ith )ages *or ................................................................. (d) HeK!he )as on layAo** )ith )ages *rom .......................... to ................................... (e) HeK!he )as on stri8e *rom .................................. to ............................... '. In case# the IPKIF is paid any )ages *or any o* the days *alling during the abo9ementioned period subse.uently# the same )ill be noti*ied to you in due course. 4. The day proceeding the *irst day o* absence )as;K)as not a holiday *or the Insured PersonKInsured Foman. DateG..................... !ignature ........................ =ame in bloc8 letter and designation .................................... Code =o. .................................... ; !tri8e out i* not applicable

%IRE". >7R?A11 Accident ,oo% E<9E4FEES? S1A1E I=S>3A=$E $43943A1I4= (Regulation CC) ! D T = S A I! D Ia ian h .lm m si e e eu * = rt o o o aa # ,**nn d dc e = =e p o o Aa ttd= r iido t c c r .m e e ee sn st oa *n d I n7 @c uc ru ep da t Pi eo rn s oo n* t h e e

m p l o y e e C N D T P 1 ' 4 2 % C I 3 $ 1 1 1 1 & 1 ' 4

F = != R hai ae am gm m t enea # a# r e t 8 (ouas acr d# cced t u ri l pae* yans t ds a ) i n aoday s nen # sd t i hago ednc dac i rt u nei p @ s oa us nt r i eaoo dn* n d

p to es h* ri e sg t onp) naeo tr dus ) or oi i ent n n go) e r hs a os tt e hm s t ea h8 et e hs tu im t m bh e e i om e * pn rt aer cs y cs iii don en nt t oh *e tA hc ec i pd ee rn st

o nH (o so )8 g i 9 i n g n o t i c e 11111 2%CI3

%3AC1RE". >7R?A1' Accident 3eport from Employer EmployeesQ !tate Insurance Corporation (Regulation C3) 1. =ame and Address o* >actoryKEstablishment and Telephone =o. '. =ature o* Industry or business 4. EmployerQs Code =o. %. =ame and address o* in@ured person C. !e( and Age 3. Insurance =o. 1&. !hi*tKHrs. o* )or8 on the date o* accident 1'. Date and hour o* accident 12. =ature and e(tent o* in@ury (e.g. *atal# loss o* *inger# *racture o* leg# scald etc.) 1C. Address o* premises )here accident happened I. 7ccupation $. Department 11. Hour at )hich he started )or8 on the day o* accident 14. E(act place o* accident 1%. Bocation o* in@ury (right leg# le*t hand or le*t eye etc.) 1I. Date o* death in case the in@ured person dies 2. Hranch 7**ice

13. In case the accident happened )hile meeting an emergency# please stateG/ (i) Its nature / (ii) Fhether the in@ured person# at the time o* the accident )as employed *or the purpose o* his employerQs trade or business in or about the premises at )hich the accident too8 place/ 1$. DispensaryKI?P allotted to in@ured person '&. Dr or Dispensary or Hospital *rom )here in@ured person recei9ed or is recei9ing treatment

'1. =ame and Address o* )itnessG/ 1. '.

Ees ''. Fhether )ages in *ull or part are payable to him *or the day o* accident '4. Fhether the in@ured person )as an employee under section '($) o* the Act on the day o* accident '2. Fhether contribution )as payable by him *or the day on )hich accident occurred '%. Cause o* accident/ (a) !tate e(actly )hat the in@ured person )as doing at the time o* accident i.e. brie* description o* ho) the accident occurred TTTTTTTTTTTTTTTTTT. (b) Fas the in@ured person# at the time o* accident# acting in contra9ention o*/ (1) the pro9ision o* any la) applicable to him orTTTTTTTTTTTT. or (') any orders gi9en by or on behal* o* his employer orTTTTTTTTTT or (4) acting )ithout instructions *rom his employerTTTTTTTTTTTTTT.. (c) In case reply to b(1)# (') or (4) is Ees# state )hether the act )as done *or the purpose o* and in connection )ith the employerQs trade or business 'C. In case the accident happened )hile tra9elling in the employerQs transport# state )hether the in@ured person )as tra9ellingG/ (1) as a passenger to or *rom his place o* )or8 (') )ith the e(press or implied permission o* his employer (4) the transport is being operated by or on behal* o* the employer or some other person by )hom it is pro9ided in pursuance o* arrangement made )ith the employer# and Ees

=o

=o

(2) the 9ehicle )as beingKnot being operated in the ordinary course o* public transport ser9ice I certi*y that to the best o* my 8no)ledge and belie*# the abo9e particulars are correct in e9ery respect Date o* dispatch o* !ignature o* the EmployerTTTTTT. reportTTTTTT =ame in bloc8 lettersTTTTTTTT. DesignationTTTTTTTTTTTT

()ith !tamp) (>or 7**icial +se) Diary =o. o* accident register and dateTTTTTTTTTTTT!ignature o* H.?TTTTTTTTTTTTTTTTT. =ote2+Accident Report is re.uired to be submitted to the appropriate Hranch 7**ice as )ell as to Insurance ?edical 7**icerKI.?.P. )ithin '2 hours o* the receipt o* notice o* in@ury. In case o* *atal or serious accidents# it must be submitted immediately to a9oid legal penal action under section 3%.

C'RE". >7R?A14 (In Duplicate); 5eath $ertificate (>or DependantQs Hene*it or >uneral E(penses) EmployeesQ !tate Insurance Corporation (Regulations I$ and $%AC) Hoo8 =oTTTTTTTTTT. !tamp o* Dispensary S12 =oHHHHHHHH

=ame o* the deceased Insured PersonTTTTTTTTTTTTTTTTTTTTTTTTTT..TT.sK)Kd o* TTTTTTTTTTTTTTTTTTTTTTTTTTTT.. Insurance =oTTTTTTTTTTTTTTTTTT. I certi*y that in my opinion the abo9e named deceased Insured Person died on theTTTTTTTTTTTTTTTTday o*TTT as a result o* an in@uryKdue to;TTTTTTTTTTTTTTTTTTTT I ;;had been attending himKher *or pro9iding medical bene*it be*ore hisKher death and I attended himKher *or the last time on theTTTTTTTTTTTday o*TTTTTTTTTTT !ignatureTTTTTTTTTTTTT Insurance ?edical 7**icerKI.?.P. =ame in bloc8 letters and rubber stamp Any other remar8s by the ?edical 7**icer DatedGTTTTTTTTTTTTTT ;Please indicate the name o* the disease ;; ?ay be suitably amended i* the Insurance ?edical 7**icerKI.?.P. has not attended the deceased person be*ore hisKher death

I'RE". >7R?A12 $laim for 9ermanent 5isablement ,enefit EmployeesQ !tate Insurance Corporation (Regulation ICAA) I TTTTTTTTTTTTTTTT..sK)Kd TTTTTTTTTTTTTTTTTT.. Insurance =o. TT. TTT ha9ing been declared as permanently disabled by the ?edical HoardK?edical Appeal Tribunal KEmployeesQ Insurance Court# claim Permanent Disablement Hene*it accordingly *or the period *rom TTTTTT.. to TTTTTT.. The amount due may be paid to me by money orderKin cash at Hranch 7**ice TTTTTTTTTTTTTTTT.. !ignature or thumb impression o* the Claimant =ame in bloc8 letters TTTTTTTTTT.. and Address TTTTTTTTTTTTT... TTTTTTTTTTTTTTTTTT.. Dated TTTTTTTTTT.. Important* Any person )ho ma8es a *alse statement or representation *or the purpose o* obtaining bene*it# )hether *or himsel* or *or some other person# commits an o**ence punishable )ith imprisonment *or a term )hich may e(tend up to si( months or )ith a *ine up to Rs '&&&# or )ith both

C4RE". >7R?A1% $laim /orm for 5ependant?s ,enefit E/2&"3''.A S$($' I).5#()1' C"#2"#($%") (Regulation 3&) =ame o* the deceased Insured Person TTTTTTTTTTT..Ins. =o TTTTTTTTTTTT!KFKD o* TTTTTTTTTTTTTTTTTTT.Date o* Death TTTTTTTTTTTT.Bast employed as TTTTTTTTTTTTTT.. by TTTTTTTTTTTTTTTTTT. IKFe the *ollo)ing# being dependants o* the abo9e named deceased Insured Person# hereby claim and accordingly apply *or dependantQs bene*it on account o* hisKher deathG =ame o* the dependant 1 !e( Age or year o* birth 4 ?arital status 2 Relationship )ith the deceased % Present Address C =ame o* guardian in case o* minor I

'

IKFe declare that the particulars gi9en abo9e are true to the best o* myKour 8no)ledge and belie* IKFe also declare that to the best o* myKour 8no)ledge and belie*# there is no other dependant entitled to claim DependantQs Hene*it in rKo the death o* the abo9e noted deceased I.P.# sa9e and e(cept those mentioned abo9e 1. TTTTTTTTTTTTTT. '. TTTTTTTTTTTTTT. Si&natureI 4. TTTTTTTTTTTTTT. 2. TTTTTTTTTTTTTT. A11ES1A1I4=II Certi*ied that the declarations# as made abo9e# are true to the best o* my 8no)ledge and belie* =ame in bloc8 letters and Rubber !tamp or !eal o* the Attesting Authority !ignature TTTTTTTTTTTT. Designation TTTTTTTTTTT.

; All ma@or dependants should sign indi9idually and the guardian to sign in case o* a minor dependant ;; This certi*icate is to be gi9en by (i) an o**icer o* the Re9enue# ,udicial or ?agisterial Departments o* "o9ernment# or (ii) a ?unicipal Commissioner# or (iii) a For8menQs Compensation Commissioner# or (i') the Head o* the "ram Panchayat under the o**icial seal o* the Panchayat# or (') ?.B.A.K?.P.# ('i) "aLetted 7**icer# or ('ii) a member o* Bocal CommitteeKRegional Hoard o* the E!I Corporation# or ('iii) any other authority considered appropriate by the Hranch ?anager. Important* Any person )ho ma8es a *alse statement or representation *or the purpose o* obtaining bene*it# )hether *or himsel* or *or some other person# commits an o**ence punishable )ith imprisonment *or a term )hich may e(tend up to si( months or )ith a *ine up to Rs '&&&# or )ith both

C2RE". >7R?A1C $laim for 9eriodical 9ayments of 5ependants? ,enefit Employees? State Insurance $orporation (Regulation 34AA) =ame o* the deceased Insured Person TTTTTTTTTTT.Ins. =o TTTTTTTTTTTT.I TTTTTTTTTTTTTTT. being the TTTTTTTTTTTTTTTTTT o* the abo9e named deceased Insured Person and also being hisKher dependant# do hereby claim DependantsQ Hene*it *or the period *rom TTTTTTTTTTT.. to TTTTTTTTTTT.. The amount due may be paid to by money order me In cashKby che.ue at Hranch 7**ice I also declare that/ ;(i) I ha9e not married;KreAmarried# so *ar (Applicable only in case o* a *emale dependant) ;(ii) I ha9e not attained the age o* 13 years (Applicable in case o* minor maleK*emale dependant) ;(iii) I am still in*irm (Applicable only in case o* a legitimateKadopted; in*irm son or a legitimateKadopted; unmarried in*irm daughter )ho has attained 13 years o* age. The claim to be accompanied# i* re.uired# by a certi*icate o* speci*ied authority) Date TTTTTTTTT. ;;!ignature or Thumb impression o* the Claimant Present Address TTTTTTTTTTTT TTTTTTTTTTTTTTTT.TT =ame in bloc8 letters o* or ClaimantK"uardian ;;;!ignatureKThumb impression o* the "uardian *or TTTTTTTTTTTTTTTT.. (=ame o* the minor Dependant) through .(=ame o* the "uardian)TTTT.. hisKher TTTTTTTTTTTTTTT. (Relationship )ith the ?inor) ; Please stri8e out )hiche9er is not applicable ;; Applicable in the case o* a claim by a ma@or dependant

;;; Applicable in the case o* a claim *or a minor dependant :Please re*er to Rule %3 o* the E!I (Central) Rules# 1$%&<

C% RE". >7R?A1I $ertificateB=otice of 9re&nancy <aternity ,enefit E?PB7EEE!Q !TATE I=!+RA=CE C7RP7RATI7= (Regulation 3I) !ignature or thumb impression o* the Insured Foman EmployerQs Code =o Hoo8 =o. TTTTTTTT. TTTTTTTT Insured FomanQs =ame !erial =o. TTTTTTTT. TTTTTTTT Insurance =o TTTTTTTT Fi*eKDaughter o* TTTTTTTT !tamp o* the Dispensary Certi*ied that I ha9e e(amined the abo9e mentioned Insured Foman today and that in my opinion she pregnant and her pregnancy appears to be TTTTTTTTTTTTT )ee8s old !ignature o* mid)i*e# i* any DatedG TTTTTTTTTT !ignature or counterA signature o* the Insurance ?edical 7**icer =ame in bloc8 letters and Rubber !tamp Any other remar8s TTTTTTTTTTTT..T. TTTTTTTTTTTTTTTTTTTTT I# TTTTTTTTTTTTTTTTTT Insurance =o. TTTTTT.. TTTTTTTT. Fi*eKdaughter o* TTTTTTTTTTTTTTTT.. hereby gi9e notice o* pregnancy Present addressG TTTTTTTTTTTTTTTTTTT TTTTTTTTTTTTTTTTT.TTTTTTTT. PresentKlast employer TTTTTTTTTTTTTTTTTTTTTTTTTTTTTT DateG TTTTTTTTTT. !ignature or thumb impression o* the Insured Foman

CCACI RE". >7R?A13 $ertificate of Expected $onfinementB$onfinementB <iscarria&e <aternity ,enefit E?PB7EEE!Q !TATE I=!+RA=CE C7RP7RATI7= (Regulations 33 and 3$) !ignature or thumb impression o* the Insured Foman EmployerQs Code =o. TTTTTTTTT Hoo8 =o. TTTTTTTT. !erial =o. TTTTTTTT Insured FomanQs =ame TTTTTT.. TTT. Insurance =o TTTTTTTTTTT. Fi*eKDaughter o* TTTTTTTTTTT. !tamp o* the Dispensary I;. Certi*ied that I ha9e e(amined the abo9ementioned Insured Foman today and that in my opinion she may e(pect to be con*ined on or about TTTTTTTTTTT.. II;. Certi*ied that I attended the abo9ementioned Insured Foman in connection )ith her con*inementK miscarriage at TTTTTTTTTT.TT.TTT (address) and that she )as there deli9ered o* a child on the TTTTTTTTT. day o* TTTTTT.. !ignature o* mid)i*e# i* any DateGTTTTTTTTT. Any remar8s TTTTTTTTTTTTTTT. TTTTTTTTTTTTTTTTTTTTT !ignature or counterAsignature o* the Insurance ?edical 7**icer =ame in bloc8 letters and Rubber !tamp ; Delete )hiche9er is not applicable

C3AI&RE". >7R?A1$ $laim for <aternity ,enefit and =otice of Aor% E?PB7EEE!Q !TATE I=!+RA=CE C7RP7RATI7= (Regulations 33# 3$ and $1) !ignature or thumb impression o* the Insured Foman Hoo8 =o. TTTTTTT EmployerQs Code =o. Insured FomanQs =ame T..TTTTTTTTTT. Insurance =o. Fi*eKDaughter o* TTTTTTT..TTTTT. !erial =o. TTTTTT.

!tamp o* the Dispensary I# the abo9ementioned Insured Foman hereby claim ?aternity Hene*it *or e(pected con*inementK con*inement;Kmiscarriage )ith e**ect *romTTTTTTTT.. I *urther declare that I ha9e ceased;Kshall cease to )or8 *or remuneration )ith e**ect *rom the a*oresaid date ;I do hereby gi9e notice that I ha9e ta8en upKshall ta8e up )or8 *or remuneration )ith e**ect *rom TTTTTT I ha9e dra)n maternity bene*it only up to TTTTTTTTT. Present Employer;; TTTTTTTTTTTTT. Department# shi*t and occupation TTTTTTTT Present address TTTTTTTTTTTTTTT !ignatureKThumb impression o* the TTTTTTTTTTTTTTTT Insured Foman =ame o* the Hranch 7**iceTTTTT DateG TTTTTTTT ; Please delete )hiche9er is not applicable ;; I* not in employment# mention the particulars o* last employer Important* 1. =o )or8 *or remuneration shall be ta8en up during the period *or )hich ?aternity Hene*it is being claimed or is to be claimed '. =otice *or resumption o* )or8 must be sent be*ore any )or8 is ta8en up 4. Any person )ho ma8es a *alse statement or representation *or the purpose o* obtaining bene*it# )hether *or hersel* or *or some other person# commits an o**ence punishable )ith imprisonment *or a term )hich may e(tend up to si( months# or )ith a *ine up to Rs '&&&# or )ith both

I1RE". >7R?A'& $laim for <aternity ,enefit after the death of an Insured Aoman lea'in& behind the $hild EmployeesQ !tate Insurance Corporation (Regulation 3$AA) Claim arising *rom the death on TTTTTTT..TTTTTTT.. o* ?s TTTTTTTTTTTTTT )i*eKdaughter o* TT.. TTTTTTTTTTTTTT.# ha9ing Insurance =o TTTTTTTTTTTTTT and last employed by ?Ks TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT. I TTTTTTTTTTTTTTTTTTTTTTTTTTTTTT.. ;being related to the abo9e named deceased Insured Person as her TTTTTTTTTTTTTTTTT. and being her nomineeKbeing her legal representati9e (applicable i* the I.F. dies lea9ing no nominee)# hereby claim ?aternity Hene*it *or the period *rom TTTTTTTT. to TTTTTTTTTTT.. I also declare that/ ;;(i)the deceased Insured Foman died on TTTTTTTTTTTTTT.. lea9ing behind the child )ho is still ali9e5 or ;;(ii) the deceased Insured Foman died on TTTTTTTTTTTTTTT lea9ing behind the child )ho also died on TTTTTTTTTTTTT. The amount due may be paid to me by ?oney 7rderKin cash at Hranch 7**ice I *urther declare that the particulars# as gi9en hereinabo9e# are true to the best o* my 8no)ledge and belie* Date TTTTTTTTTTTTTTTTTTTTT. TTTTTTTTTTTTT.. !ignatureKThumb impression o* the Claimant =ame in bloc8 letters andTTTTTTTTT.. Address o* claimantTTTTTTTTTTTT. TTTTTTTTTTTTTTTTTTTTT.. ATTE!TATI7= ;;;Certi*ied that the declarations# as made hereinabo9e# are true to the best o* my 8no)ledge and belie* =ame in !ignature )ith date TTTTTTTTTTTT bloc8 DesignationTTTTTT..TTTTTTTTT.. letters and Rubber !tamp or !eal o* the

Attesting Authority ; !tri8e out this line i* not applicable ;; Delete either (i) or (ii)# as may not be applicable in the case ;;; This certi*icate is to be gi9en by ( i) an o**icer o* the Re9enue# ,udicial or ?agisterial Department5 or (ii) a ?unicipal Commissioner# or (iii) a For8menQs Compensation Commissioner5 or (i') the Head o* "ram Panchayat under the o**icial seal o* the Panchayat# or ?.B.A.K?.P.5 or (') a "aLetted 7**icer o* the CentralK!tate "o9ernmentK?ember o* the Bocal CommitteeKRegional Hoard5 or ('i) any other authority considered as appropriate by the Hranch ?anager concerned Important* 1. This claim *orm# duly *illed up# is re.uired to be submitted to the appropriate Hranch 7**ice# together )ith a death certi*icate in >orm '2AH# )ithin 4& days o* the death o* the Insured Foman '. Any person )ho ma8es a *alse statement or representation *or the purpose o* obtaining bene*it# )hether *or himsel* or *or some other person# commits an o**ence punishable )ith imprisonment *or a term )hich may e(tend up to si( months or )ith a *ine up to Rs '&&& or )ith both

I1aRE". >7R?A'1 5eath $ertificate in case of $onfinement for $laimin& <aternity ,enefit EmployeesQ !tate Insurance Corporation (+nder Regulation 3$AA) !tamp o* the Dispensary Hoo8 =o. TTTTTTTTT =ame o* the deceased Insured )oman TTTTTTTTTT. FKD o* TTTTTTTTTTTTTT Insurance =o. TTTTTTTTTTT

!erial =o. TTTTTTT...

I certi*y that in my opinion/ (i) the abo9e named deceased Insured Foman died on TTTTTTTTTTTT as a result o* TTT.TTTTTTT.. during her con*inementK;during a period o* TTTTTTTTTTTTT... )ee8s TTTTTTTTTTT (Cause o* death) immediately *ollo)ing her con*inement# lea9ing behind the child ;(ii) the said child also died on TTTT.TTTTTTTTTTTTTTTTTT.. as a result o* TTTTTTTTTTTTTTTTTTTTTTTTTT... Also certi*ied that I had been attending her;Kand also her said child *or pro9iding medical bene*it be*ore ;her deathKher said childQs death and I attended her *or the last time on TTTTTTTTTTTTTTTTTTTT and her said child *or the last time on TTTTTTTTTTTTTTT Any other remar8s TTTTTTTTTTTTTTT. TTTTTTTTTTTTTTT. TTTTTTTTTTTTTTTT. Date TTTTTTTT. !ignature o* Insurance ?edical 7**icerKInsurance ?edical Practitioner Rubber !tamp and name in bloc8 letters =ote*(1); Please delete )hiche9er is not applicable

(') The language may be suitably amended i* the Insurance ?edical 7**icerKInsurance ?edical Practitioner had not attended the deceased person be*ore herKher childQs death

I4RE". >7R?A'' /uneral Expenses $laim /orm EmployeesQ !tate Insurance Corporation (Regulation $%AE) Claim arising out o* death on TTTT.TTTTTTTTTTTTTT. o* TTTTTTTTTTTTTT. sK)Kd o* TTTTTTTTTTTTTTTTTTTTTT. aged TTTTTTTTTTT. years# ha9ing Insurance =oTT.. TT. and last employed as TTTTTTTT.. TTTTTTTTTTTTTTTTTTTTTTTTTTTTT. by ?Ks TTTTTTTTTTTTTTTTTTT.. Code =o. TTTTTTTTTTTTTTT.T I TTTTTTTTTT.. sK)Kd o* TTTTTTTTTTTTTTTTT.. aged TTTTTTTTTTTTTTT.TTT.. years declareG/

;(i) that I am the eldest sur9i9ing member o* the *amily o* the deceased Insured Person# )hose particulars are *urnished hereinabo9e# and that I actually incurred an e(penditure o* Rs TTTTTTTTT.. (Rupees TTTTTTTTTTTTTTTTTTTTT only) necessary *or the *uneral o* the said deceased person or ;(ii) that the deceased Insured Person# )hose particulars are *urnished thereinabo9e# did not ha9e a *amilyK)as not li9ing )ith hisKher *amily at the time o* hisKher death and that I actually incurred an e(penditure o* Rs TTTTTTTTTTTTTT (Rupees TTTTTTTTTTTTTTTTTTTTTT.. only) on the *uneral o* the deceased Insured Person Accordingly# I do hereby claim *uneral e(penses *or the amount o* Rs TTTTTTTTTTTTTTTTTTTTT..TT (Rupees TTTTTTTTTTTTTTTTT. only) TTTTTTTTTTTTTTTTTTTTTT Date =ame !ignatureKThumb impression o* the Claimant TTTTTTTTTTTTTTTTTTT. in . bloc8 letters ATTE!TATI7= ;;Certi*ied that the declarations# as made hereinabo9e# are true to the best o* my 8no)ledge and belie*

=ame in !ignature )ith date TTTTTTTTTTTT bloc8 DesignationTTTTTT..TTTTTTTTT.. letters and Date Rubber TTTTTTTTTTTTTTTTTTT !tamp or !eal o* the Attesting Authority ; Delete either (i) or (ii)# )hich may not be applicable in the case ;; This certi*icate is to be gi9en by ( i) an o**icer o* the Re9enue# ,udicial or ?agisterial Department5 or (ii) a ?unicipal Commissioner5 or (iii) a For8menQs Compensation Commissioner5 or (i') the Head o* "ram Panchayat under the o**icial seal o* the Panchayat# or ?.B.AK?.P.5 or (') a "aLetted 7**icer o* the CentralK!tate "o9ernment# Bocal CommitteeKRegional Hoard5 or ('i) any other authority considered as appropriate by the Hranch ?anager concerned Important* Any person )ho ma8es a *alse statement or representation *or the purpose o* obtaining bene*it# )hether *or himsel* or *or some other person# commits an o**ence punishable )ith imprisonment *or a term )hich may e(tend up to si( months or )ith a *ine up to Rs '&&& or )ith both =ote* In the case o* a minor# the guardian should sign the claim *orm on behal* o* the minor and then add the *ollo)ing belo) hisKher signatureG/ (=ame o* the ?inor) through (=ame o* the "uardian) hisKher (Relationship )ith the ?inor)

I2RE". >7R?A'4 (To be submitted along )ith claim o* ,une and December) Eife $ertificate for 9ermanent 5isablement ,enefit E?PB7EEE!Q !TATE I=!+RA=CE C7RP7RATI7= (Regulation 1&I) Insurance =o. o* Permanently disabled person ;Certi*ied that !hriK!mt TTTTTTTTTTTTTTT )KsKd o* TTTTTTTTTTTT is ali9e thisTTTTTTTTTTT. day o* TTTTTTTTT. '& ..TTT. !ignature TTTTTTTT.. =ame in bloc8 letters o* signing Claimant TTTTTTTTT. Designation )ith Rubber !tampK!eal o* the Attesting Authority

DateTTTTTTTTT. Important* Any person )ho ma8es a *alse statement or representation *or the purpose o* obtaining bene*it )hether *or himsel* or *or some other person# commits an o**ence punishable )ith imprisonment *or a term )hich may e(tend up to si( months or )ith a *ine up to Rs '&&& or )ith both ; This certi*icate is to be gi9en by (i) an o**icer o* the Re9enue# ,udicial or ?agisterial Department5 or (ii) a ?unicipal Commissioner5 or (iii) a For8menQs Compensation Commissioner5 or (i') the Head o* "ram Panchayat under the o**icial seal o* the Panchayat5 or (') ?.B.A.K?.P.5 or ('i) a "aLetted 7**icer o* the CentralK!tate "o9ernment5 or ('i) a member o* the Regional HoardKBocal Committee o* the E!IC5 or ('iii) any other authority considered as appropriate by the Hranch ?anager concerned

I%RE". >7R?A'2 (To be submitted along )ith claim o* ,une and December) 5eclaration and $ertificate for 5ependant?s ,enefit E?PB7EEE!Q !TATE I=!+RA=CE C7RP7RATI7= (Regulation 1&IAA) =ame o* the deceased Insured PersonTTTTTTTT.. Ins. =o.

I TTTTTTTTTTTTTTTTTT# being the TTTTTTTTTTTT..o* the abo9e named deceased Insured Person and also being his dependant# do hereby solemnly declareG/ ;(i) that I ha9e not marriedKremarried so *ar (To be gi9en only by a *emale dependant) ;(ii) that I ha9e not yet attained the age o* eighteen years (To be gi9en only in respect o* a minor male or *emale dependant) ;(iii) that I ha9e attained the age o* eighteen years but continue to be in*irm (To be gi9en by a legitimateKadopted in*irm son or by a legitimateKadopted in*irm daughter. Certi*icate as speci*ied# to be attached# i* re.uired) Present AddressG TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT.. DateTTTTTTTTTTTT TTTTTTTTTTTTTT !ignature or thumb impression o* the dependant or TTTTTTTTTTTTTT !ignature or thumb impression o* the "uardian in case o* a minor dependant =ame o* the minorTTTTTTT.. ThroughTTTTTTTTT. (=ame o* the "uardian) hisKherTTTTTTTT (Relationship )ith the ?inor) )KsKd o*

=ame in bloc8 letters o* signing claimant

;;Certi*ied

that

CERTI>ICATE !hriK!mtK-umari TTTTTTTTTTTT..

TTTTTTTTTTTT.. is ali9e this day# theTTT.. day o*TTTT '&TTTTT. and that the declarations made abo9e are true to the best o* my 8no)ledge and belie* =ame in bloc8 letters and Rubber !tamp or !eal o* the Attesting Authority !ignature TTTTTTTT. DesignationTTTTTTTT.

DateTT

; !tri8e out )hiche9er is not applicable ;; This certi*icate is to be gi9en by ( i) an o**icer o* the Re9enue# ,udicial or ?agisterial Department5 or (ii) a ?unicipal Commissioner5 or (iii) a For8menQs Compensation Commissioner5 or (i') the Head o* "ram Panchayat under the o**icial seal o* the Panchayat5 or (') ?.B.A.K?.P.5 or ('i) a "aLetted 7**icer o* the CentralK!tate "o9ernment5 or ('ii) a member o* the Regional HoardKBocal Committee o* the E!IC5 or ('iii) any other authority considered appropriate by the Hranch ?anager concerned Important* Any person )ho ma8es a *alse statement or misrepresentation *or the purpose o* obtaining bene*it# )hether *or himsel* or some other person# commits an o**ence punishable )ith imprisonment *or a term )hich may e(tend up to si( months or )ith a *ine up to Rs '&&& or )ith both

SCHEDULE I I3:;;;< SCHEDULE II I3:;;;< 79[SCHEDULE III :3e&ulation 7;,< COMMUTATION BALUES :OR PERMANENT DISA8LEMENT 8ENE:IT A&e last birthday of insured person on the date on which the application for commutation is recei'ed in the appropriate office 1 1I years and belo) 13 years 1$ years '& years '1 years '' years '4 years '2 years '% years 'C years 'I years '3 years '$ years 4& years 41 years 4' years 44 years 42 years 4% years 1he factor with which the daily rate of benefit is to be multiplied A&e last birthday of insured person on the date on which the application for commutation is recei'ed in the appropriate office 1 2' years 24 years 22 years 2% years 2C years 2I years 23 years 2$ years %& years %1 years %' years %4 years %2 years %% years %C years %I years %3 years %$ years C& years 1he factor with which the daily rate of benefit is to be multiplied

' %C$& %CI& %CC& %C2& %C'& %C&& %%3& %%C& %%2& %%1& %23& %2C& %2'& %4$& %4C& %4'& %'3& %'2& %'&&

' 23C& 23&& 2I2& 2CI& 2C1& 2%2& 22I& 22&& 244& 2'%& 213& 21&& 2&'& 4$4& 43%& 4IC& 4CI& 4%$& 4%&&

4C years 4I years 43 years 4$ years 2& years 21 years CI years C3 years C$ years I& years I1 years I' years I4 years

%1C& %11& %&I& %&'& 2$I& 2$1& '3%& 'I%& 'CC& '%I& '2I& '43& ''$&

C1 years C' years C4 years C2 years C% years CC years I2 years I% years IC years II years I3 years I$ years 3& years

42&& 441& 4''& 414& 4&4& '$2& ''&& '1'& '&4& 1$%& 13C& 1I3& 1I&&

NOTI:ICATION UNDER REGULATION >7 O: EMPLOYEES STATE INSURANCE (GENERAL) REGULATIONS, 1950 It is noti*ied *or general in*ormation that the DirectorA"eneral under po)ers 9ested in him by 9irtue o* the pro9isions o* regulation 'I o* the Employees !tate Insurance ("eneral) Regulations# 1$%&# has speci*ied the *orm o* 0Certi*icate o* contributions payable1 as per Anne(ure I o* this noti*ication. >, The employers )ho ma8e payment o* contribution in time )ill continue to submit the return o* contribution under regulation 'C o* the Employees !tate Insurance ("eneral) Regulations# 1$%&# as usual. Ho)e9er# *rom the contribution period ending !eptember 1$$%# on)ards# those employers )ho are unable to submit the a*oresaid return o* contribution due to nonApayment o* contribution (employers as )ell as employees share) to the Corporation )ill be re.uired to submit the 0certi*icate o* contributions payable1 no) speci*ied# )ithin the same timeAlimit prescribed under regulation 'C o* the Employees !tate Insurance ("eneral) Regulations# 1$%&. ?, The appropriate o**ice o* the Corporation )ill start accepting the 0certi*icate o* contributions payable1 to be submitted by the de*aulting employers )ithin the time prescribed under regulation 'C o* the Employees !tate Insurance ("eneral) Regulations# 1$%&# *rom the contribution period ending !eptember 1$$%# on)ards. 4, 0The appropriate o**ice1 *or the purpose o* submission o* the said 0certi*icate o* contributions payable1 )ill be the concerned regional o**ice as already noti*ied *or the purpose o* submission o* return o* contribution under regulation 'C o* the Employees !tate Insurance ("eneral) Regulations# 1$%&. 5, In the *irst instance# the pro9isions o* this noti*ication )ill come into *orce in the !tates o* +ttar Pradesh# Haryana# Delhi# ?aharashtra# Pun@ab# Ra@asthan# -arnata8a and Fest Hengal )ith e**ect *rom the contribution period ending !eptember 1$$%# on)ards.

A==EP+REAI CERTI:ICATE O: CONTRI8UTIONS PAYA8LE Employer s Code =o. ................... Employees !tate Insurance Corporation $ertificate of contribution (Regulation 'I) =ame and TTTTTTTTTTTTT.. address o* the TTT........................................................... *actory or establishment Particulars o* the principal employer (a)=ame TTTTTTTTTTTTT.. TTT........................................................... (b)Designation TTTTTTTTTTTTT.. TTT........................................................... (c)Residential TTTTTTTTTTTTT.. address TTT........................................................... period *rom......................................................................to............................................................... I *urnish belo) the details o* the employer s and employee s share o* contribution in respect o* the under mentioned insured persons. I hereby declare that the details include e9ery employee employed directly or through an immediate employer or in connection )ith the )or8 o* the *actoryKestablishment or any )or8 connected )ith the administration o* the *actoryKestablishment or purchase o* ra) materials# sale or distribution o* *inished products# etc.# to )hom the contribution period to )hich this certi*icate relates# applied and that the contribution in respect o* employer s and employee s share has been correctly calculated and is payable in accordance )ith the pro9isions o* the Act and Regulations relating to the payment o* contributions. Total contribution payable is amounting to Rs. .........comprising o* Rs. ............as employer s share and Rs. ................as employee s share (Total o* column C o* the certi*icate). 1. I declare that the particulars gi9en abo9e are correct to the best o* my 8no)ledge and belie*. '. I declare that the *actoryKestablishment )as co9ered under the Employees !tate Insurance Act during the contribution period to )hich the abo9e in*ormation pertains. Place G ........................... .............................................. Date G .............................. !ignature .............................................. Designation

Important instructions * 1. I* any I.P. is appointed *or the *irst time andKor lea9e ser9ice during the contribution period# indicate OA..... or OB.... :date in the remar8s column (=o. 3)<. '. Please indicate insurance numbers in chronological (ascending) order. 4. >igures in columns 2# % and C shall be in respect o* )age periods ended during the contribution period. 2. In9ariably stri8e total o* columns 2# % and C. %. =o o9erA)ritings shall be made. Any corrections should be signed by the employer. C. E9ery page should bear *ull signature and rubber stamp o* the employer. I. ODaily )ages in column I shall be calculated by di9iding *igures in column % by *igures in column 2 to t)o decimal places. =ote2/!ubmission o* this certi*icate o* contributions payable does not absol9e the employer o* the responsibility to submit the return o* contribution under regulation 'C or any other returns enshrined in 9arious pro9isions o* the Employees !tate Insurance Act and the Employees !tate Insurance ("eneral) Regulations# 1$%&. Sl2 =o2 Ins2 =o2 =ame of insured person =o2 of days for which wa&es paid (2) 1otal amount of wa&es paid (%) Employees contribution deducted 5aily wa&es 3emar% s

(1)

(')

(4)

(C)

(I)

(3)

Place G ................ Date G .................

............................................................ !ignature ........................................................... Designation Rubber !tamp o* employer S"5#1' C =otification =o2 J)""B18)1)98)I=S2IJ, dated 71) )19982 ;;;