| FORM 1 |
Employee registration form. |
| To whom |
Employer |
| By whom |
Employee |
| When is it submitted |
Within 10 days of appointment of employee should reach the concerned branch office |
| FORM 1 |
Employer’s registration form. |
| To whom |
- |
| By whom |
Employee |
| When is it submitted |
Within 15 days after the act becomes applicable & obtain the Employer’s code for use in all the ESIC forms |
| FORM 01 (A) |
Form of Annual Information. |
| To whom |
- |
| By whom |
Employer |
| When is it submitted |
To be filed once a year about the return of firm/ establishment particulars. (in a given format) |
| FORM 2 |
Family declaration form. |
| To whom |
Employer |
| By whom |
Employee |
| When is it submitted |
The form is to be filled at the time of adding or deleting any family member |
| FORM 3 |
This is a form for return of declaration. |
| To whom |
- |
| By whom |
Employer |
| When is it submitted |
Within 10 days of date on which declaration form is submitted |
| FORM 9 |
This form is used for making claims for sickness, temporary disablement benefit, and maternity benefit. |
| To whom |
Concerned Branch office |
| By whom |
Employee |
| When is it submitted |
When one has to claim benefit of the above-mentioned issue |
| FORM 11 |
Accident book |
| To whom |
- |
| By whom |
Employer |
| When is it submitted |
Preserve a book readily accessible for at least five years or till the time it is filled completely |
| FORM 12 |
This is an accident report form from the employer. |
| To whom |
Branch office or ESI dispensary concerned |
| By whom |
Employer |
| When is it submitted |
Within 24 hours of accident or death |
| FORM 14 |
This is a claim form for permanent disability benefit. |
| To whom |
ESIC |
| By whom |
Insured Person (can be the employee) |
| When is it submitted |
When one has to avail the benefit |
| FORM 15 |
This is a form used for making claims for availing dependent benefits. |
| To whom |
Local Committee of ESIC, Concerned Branch manager or Workmen’s compensation commissioner |
| By whom |
Dependent of the deceased |
| When is it submitted |
- |
| FORM 16 |
For making claims for periodical payment of disablement benefit, this form can be used. |
| To whom |
Concerned Branch office or ESIC Committee |
| By whom |
Dependent of the insured |
| When is it submitted |
When one has to claim benefit for certain duration |
| FORM 19 |
In order to claim maternity benefits and notice of work, this form has to be submitted. |
| To whom |
Concerned Branch office |
| By whom |
Insured Woman |
| When is it submitted |
Claim at the time of expected confinement or miscarriage |
| FORM 20 |
This form can be used for availing maternity benefits after the death of the insured person. |
| To whom |
Concerned Branch office |
| By whom |
Any concerned person of the deceased insured woman |
| When is it submitted |
Submitted within 30 days of death with a death certificate |
| FORM 22 |
This form is used for making a claim for funeral expenses. |
| To whom |
Local Committee of ESIC, Concerned Branch manager or Workmen’s compensation commissioner |
| By whom |
A nominee on behalf of surviving eldest member of family |
| When is it submitted |
When the insured has died and one has to avail the expenses of his funeral |
| FORM 23 |
This form is life certificate form that is required to avail the permanent disablement benefit. |
| To whom |
Local Committee of ESIC, Concerned Branch manager or Workmen’s compensation commissioner |
| By whom |
Insured Person |
| When is it submitted |
During June and December with appropriate claims |
| FORM 24 |
This form is a declaration and certificate for availing disablement benefit. |
| To whom |
M.L.A, M.P, Municipal Commissioner, Local Committee of ESIC, Concerned Branch manager or Workmen’s compensation commissioner |
| By whom |
Nominee of insured person |
| When is it submitted |
Declaration cum certificate of claims in a given format during June and December |
| FORM 32 |
Wage-contributory record for disablement benefit. |
| To whom |
Manager Branch Office |
| By whom |
Employer |
| When is it submitted |
- |
| FORM 37 |
Certificate of re-employment or continuous employment. |
| To whom |
Branch office |
| By whom |
Employer |
| When is it submitted |
When the job duration is over and one wants to continue or re-join if left the job earlier |
| FORM 53 |
Application form for change in particulars of insured person. |
| To whom |
Medical Officer |
| By whom |
Employer |
| When is it submitted |
When there has been a change in the particulars of insured |
| FORM 63 |
Declaration form with regards to payment to the legal heir. |
| To whom |
Government official, Tehsildar, Office of Revenue |
| By whom |
Legal heir of Insured employee |
| When is it submitted |
At the time of claiming the benefit |
| FORM 72 |
This form is used to request for a duplicate ESIC smart card request. |
| To whom |
Manager at ESIC office |
| By whom |
Employee |
| When is it submitted |
When one has lost the ID card or family card slip |
| FORM 86 |
Certificate of employment. |
| To whom |
- |
| By whom |
Employer |
| When is it submitted |
Done to confirm from which date the employee is working in the factory |
| FORM 105 |
Certificate of entitlement. |
| To whom |
New ESIC Dispensary |
| By whom |
Employer |
| When is it submitted |
When an employee is on temporary duty or authorized leave |
| FORM 142 |
This form is used for making claims for compensation for loss of earnings and conveyance allowance. |
| To whom |
- |
| By whom |
B. Employer
C. Employee |
| When is it submitted |
- |
The above forms are available to download from the ESIC portal. They can be used for making claims under the Employees’ State Insurance scheme.
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