Scribd Logo
Upload

Welcome to Scribd!

  • ESIC Form Back

    Uploaded by

    Satyendra Rajput
    15 views1 page
    1. This document provides information about registration under the Employees' State Insurance (ESI) Act. 2. As an insured person, employees and their dependent family members are entitled to full medical care benefits from the date of registration. Other benefits include sickness benefit, temporary disablement benefit, permanent disablement benefit, and maternity benefit, subject to contribution conditions. 3. For more details, one can check the ESI Corporation website at www.esic.org.in or contact the regional or branch office.

    Original Description:

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    1. This document provides information about registration under the Employees' State Insurance (ESI) Act. 2. As an insured person, employees and their dependent family members are entitled to full medical care benefits from the date of registration. Other benefits include sickness benefit, temporary disablement benefit, permanent disablement benefit, and maternity benefit, subject to contribution conditions. 3. For more details, one can check the ESI Corporation website at www.esic.org.in or contact the regional or branch office.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    15 views1 page

    ESIC Form Back

    Uploaded by

    Satyendra Rajput
    1. This document provides information about registration under the Employees' State Insurance (ESI) Act. 2. As an insured person, employees and their dependent family members are entitled to full medical care benefits from the date of registration. Other benefits include sickness benefit, temporary disablement benefit, permanent disablement benefit, and maternity benefit, subject to contribution conditions. 3. For more details, one can check the ESI Corporation website at www.esic.org.in or contact the regional or branch office.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    ggeqr (tNsrRtJcnoN)

    1.

    qyg-.r

    .mr

    Submission of Form-1 is governed by regulations 11 & 12 of ESI (General) Regulations, 1950.

    iq"r o.qr.fl. iqrEiqql ftftuq rgso.d f{ftuq ttetzd

    s-m-'fs frR-crRn fu-qr rnror Br

    dlqrEfl *ftl fr fuqfufu-o qrfi 3{Qrfl' ot$ qTdqa 3rft}-d f; :2. "egrq" *tofdl (1)ffift(r)6q1fu.d qfrn q{ G{rlff, tn}{ erd-s sT qn?F srnr+tr-ollf}rn Ti{ (3) ot{ ara-o d frnr qo q'fu d'iqd=il w'g$f,,"silfqcr t nerr d (o.) RreTr flF @r rdr 3, s-q$ zt q{-a1 oTrg trkr o-q +i ,ro (s) .dri c{6ql-Rer gS, (4i'dr{ erda. d frt{fr eTrfrR-d sTeiqr qrrRrfi 3ruI*{FrmT qi tfe d arq'r R[r*mT'T t oefl frfuai"* b"or'=ftqr+ qfrn d sqrcftfr w yord, srTlfa B, (s) er-14-d qrnr-Fdr (qlt tg or.vr.fr. 3rfqRqq, rg+s el qrql 2 d qo-s ri of id)
    r

    'iFamily means all or any of the following relatives of an insured Person namely :dependant on the til u sfiorse (ii) a minor iegitimate or adopted child depe_ndant upon the 1.P., (iii) a child who is whollyunmarried daughter; l.p. and w6o is (a) receiving education, till he or she attains the age of 21 years (b) an i,i*oigu of tn6 who is infirm by reason of any physical or m.ental abnormality or injury and is wholly dependant on the earnings t,ul r l.p. if in* "iifOso long as the infirmity continues, iv) dependantparents (Plelse see Section 2 clause 11 of the E S I Act 1948 for details)

    3.q6qFT-q.A

    srrror<r"irq i'

    ldentity Card is Non-Transferable.

    4rrf,qm-wr d

    .Loss of lndetity eard be reported to Employer/Branch Manager lmmeddtely.


    s?FT-r

    y d qT-i of furPi q Frq}sqt /uttst q.r{rfi ?F} ilGtri{ itfuf, frrqr wql
    +i q,t furd ri or.qr.fr.GTtsft{q,1e4g et qll.Bjd
    a-dn-fir-{$

    sFS
    u

    Submission of false information attracts penal action under section 84 of ESI Act, 1948.

    qrt Tmf, rI4"rT

    zffffi of qr wo-ft tt

    *g"
    z

    og

    fufro et

    This Form duly filled in must reach the concerned Branch Office within 10 days of appointment of an Employee. Delay attracts penal action under seclion 85 of the Act, aganist employer.

    q qfi-.{iRr rr{r go{r q6' wd ftgfrn d qs fr{"d ficrq rffird yr*IT zFTqf"d-q t erqrq fr frrT .flTqt qrgq t frerc qn Rqtr-d ffiq-6 A ft-$.,=q emt-Bs d a-Eo oT-tS qlffi qff w rr-erft t't
    RTfr

    ssd qtrqr-{ d cnlqilrm o{RT<tfi qrfr Tet o-ri rr{ Fmfufuo fr-daFT sry fl q-d'n (r) fi-nfr (qtrl R-d-f,t {iz) enqrfi fr:srtril Rn6FT (s) wnft ft'nmsr f,d-dat T (+) arf}ar'n tr-d-dl*T (s) u_gfr trdE].T
    fiq-rq-d

    "Tfrd

    od?lt d frq) | ,,:__, --_^ ._^_ {^r-. . iL_^ts r. As un insu',eJ derson you and your dependant family members are entitled to full medical care from today itself. Thb other Disablement benefit (3) Permanent disablement Benefit (4)Debenefits in case includ-e {1) Sickness Ejenefit (2) Temporary pendents benefit and (5)'Maternity Benefit (in case of women employees)'subject to fulfillment of cantributory conditions.
    e.sko qrq-fiTfi d frq eqqT F-qq please
    For more details qT ytrctT oTqf-dq qr elhq l3qd Aqqrf,cwww.esic.org.inol cbntact website of ESIC at www.esic.org.in or contact Regional office or Branch Office.

    Ft.t""t

    oi

    .
    r.dtqr

    d-qf, {Ir$n mrqfffi


    d arffs:'

    FOR BFIANCH OFFICE USE ONLY

    rsr eilufg{ arlss: .Date of allotment of lns. No. :

    '

    z.3l.rrs.tte (fl'rfi fl{i +1 Date of lssue of T.l'C- :


    3.BilqglTcrq

    "

    6v q-q7r{twr:
    :

    Narne/No. of DisP.

    4 qrrr eFq fuRttwr qtr{erT'sq{er B

    qR 6i d sdqs o-t: Whether reciprocal MedicalSrrangement lnvolved. tf yes, Please lndicate.


    YIrtT[ qcrl-fi d e-mrerq Sionature of Branch. Mana

    l(es'raqlutq q1m oruoplsou


    1o

    uuol
    oefioldtug

    0u1119lo alep

    areld alels ,ou,

    ll
    Ulh

    6ulplsu.raqloqM

    uo se e0v/tlplg

    rqi qilm dgqsuolielag' rb

    lo aleg

    [[D

    Ltlbl

    &

    slpllt

    {D lPb

    lrulig S

    BI

    &lg

    up /hn

    You might also like