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Form 19

This document is a claim form from the Employees' State Insurance Corporation for maternity benefits and notice of work. It requires the insured woman's signature and details such as her name, insurance number, expected date of confinement, dates of ceasing and resuming work, benefits already received, present employer's details, and address. It notifies that no work can be done while receiving maternity benefits and work resumption notice must be sent before working again. Making false statements to obtain benefits is considered an offense.

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10K views1 page

Form 19

This document is a claim form from the Employees' State Insurance Corporation for maternity benefits and notice of work. It requires the insured woman's signature and details such as her name, insurance number, expected date of confinement, dates of ceasing and resuming work, benefits already received, present employer's details, and address. It notifies that no work can be done while receiving maternity benefits and work resumption notice must be sent before working again. Making false statements to obtain benefits is considered an offense.

Uploaded by

hdpanchal86
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

www.esicoimbatore.

org

EMPLOYEES STATE INSURANCE CORPORATION


REG. FORM- 19

CLAIM FOR MATERNITY BENEFIT & NOTICE OF WORK (Reg. 88, 89 & 91)

Signature or thumb impression of the Insured Woman Employers Code No. Insured Womans Name Insurance No. Wife/Daughter of Stamp of the Dispensary I, the above-mentioned Insured Woman hereby claim Maternity Benefit for expected confinement/Confinement*/miscarriage with effect from. . . . . . . . . . . . . . . . . I further declare that I have ceased*/shall cease to work for remuneration with effect from the aforesaid date. *I do hereby give notice that I have taken up/shall take up work for remuneration with effect from. . . . . . . . . . . . . . . . . I have drawn maternity benefit only upto. . . . . . . . . . . . . . . . . Present Employer**. . . . . . . . . . . . . . . . . Deptt. shift & Occupation. . . . . . . . . . . . . . . . . Present Address. . . . . . . . . . . . . . . . . . . . . . . .
....................................... .......................................

Book No. . . . . . . . . . . . . . . . . . . . . . . . . . Serial No. . . . . . . . . . . . . . . . . . . . . . . . .

Signature/thumb impression of the Insured Woman

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

Name of the Branch Office. . . . . . . . . .


.......

* Please delete whichever not applicable. ** If not in employment, mention the particulars of last employer.

IMPORTANT:1. 2. 3. No work for remuneration shall be taken up during the period for which Maternity Benefit is being claimed or is to be claimed. Notice for resumption of work must be sent before any work is taken up. Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for herself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months, or with a fine up to Rs.2,000/-, or with both.

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