‘GMAP, Ch-21 112/06 /5,000 Copies. ‘ag, _ EMPLOYEES’ STATE INSURANCE CORPORATION (he) waserconrrisuToRY RECORD FOR O'SABLEMENT BENEFIT ESIC -32 Incurance No, Employer's Code No. +. Name of Injured Peron 2. Branch Office to which attached 2. Date of enty 4. Date ol iniury 3 Name and ad = 6 Addross, ‘The wage / Contributory record in respect of the above: mentioned employee is as under, Signature & Stamp of employer jury occurred after commence] — Hinjury occurred belore commence-| injury occurred belore commence- ment of first Benifit period of insured] ment of frst Benefit period but atter|ment of the tirst Benefit period and Person expiry of first wage perlod in the|beloreexiy ote fs vage period in contbution period In which injury centibuonposod In whieh iy occured (on scared. A r c 1 Genetit period in whieh the! 1, Gontibuton period in which] 1.) Amountol magos actualy eared ployment inary occured, ry red or which would have been eatned had From to Frm wo ne injured person voked fora tl dy 2 Contin porod conespondng| 2 mpljea on ime ate Basis, |on te date ct accident bent peid at (1) above (1) amount of wages which woaldl As from io nave been payable tothe jute person] (i) whether monthly / fortnight 1 3. Amount of wages paid in res}nadhe worked on all working days in the| Weekky / dally rat pect of (2) above and the No. of days| completa wage period aneing inthe con. for which wages were paid vido Si|tribution period at (1) above. No... of Return of Contribution) Re, ated, (8) Whether Monthly / Fortnightly (| atready sent on ]Wookly / Dally rated Rs. 3.lhemployedon other than Time-ate| i) NO. of days basis () amount of wages eared durin| 4. Dally wage'io., ihe complete wage period ending in the| = contibution period at (1) above. 1s. Ps, i eee 5, Average Dally wage Le. (@) No. of days infu or part for which] ays he worked for wages at 3 (i) 100 above. 4."Avarage dally wage" é Dally Standard Benett Rate corresponding ‘Checked with Fletum of conte. 10.90 GIOUP PS enn butions / wage record and found Daily rate of TDB,Rs___ conect. Propared by, ‘Checked by ‘Approved by _ Manager Branch Office Investigating Otticer