FORM 7

FIRST/INTERMEDIATE/FINAL CERTIFICATE

EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulations 57, 58, 59)

Book No. ………………………………..

S.No. ……………. Stamp of dispensary Signature or Thumb Impression of the IP

Date of first Certificate of spell of Employer’s Code No. …………………

Sickness or Disablement…………………

Branch Office……………………………

Name………………………………..s/w/d/………………………………..Ins. NO. …………………

Certified that I have examined you today and that in my opinion:-

Any other remarks by the Medical Officer

………………………………..

Attestation by Med. Officer

(i)* You now need medical treatment, attendance and abstention from work on medical grounds by reason of (diagnosis) ………………………………..

(ii)* You have continued to need medical treatment, attendance and abstention from work on medical grounds upto and including this day by reason of (diagnosis) ………………… ………..……………………………

(iii)*In my opinion you will be fit to resume work tomorrow/on.

Note: The date of fitness must in now case be later than the third day after the date of examination in case of First and Final Certificate.

Date……………………………….. Signature………………………………..

Insurance Medical Officer Rubber Stamp

Name in Block Letters………………………………..

*Strike out whichever is not applicable.

Important:

Any person who makes false statement or representation for the purpose of obtaining benefit whether for himself/some other person shall be punishable with imprisonment upto 6 months or fine upto 6 months or fine upto Rs. 2000 or both.

This form should be completed and submitted WITHOUT DELAY ton the appropriate Branch Office to escape penal deduction of benefit under Regulation 64 read with Regulation 99 of ESI General Regulation 1950.

Insured person must sign, with date, the claim form to avoid delay and inconvenience.

(Deposit this certificate within 3 days with the appropriate Branch Office to avoid possible loss of benefit under Regulation 64)