ESIC Services
Sh. A.K. Agarwal, IAS, Director General, ESIC Wishes a Happy and Prosperous Deepawali to all Officers and Employees of ESIC as well as all Insured Persons, Employers and other ESIC Stakeholders .

Downloads

FORM NO. SUBJECT RELEVANT REGULATION TO BE USED BY
FORM-01 Employer's Registration Form 10 B Employer
FORM-01(A) Form of annual information on factory/establishment covered under ESI Act 10 C Employer
FORM-1 Declaration Form 11 & 12 Employer
FORM-1(A) Family Declaration Form 15-A Employer
FORM-2 Addition/Deletion in Family Declaration Form 15-B Employer
FORM-3 Return of Declaration Form 14 Employer
FORM-5 Return of Contribution 26 Employer
FORM-5(A) Advance payment of contribution 31 Employer
FORM-5 (New) Return of Contribution (New) 31 Employer
FORM-6 Register of Employees 32 Employer
FORM-9 Claim for Sickness/ Temporary Disablement Benefit/Maternity Benefit 63 & 89(B) IP/Beneficiary
FORM-11 Accident Book 66 Employer
FORM-12 Accident Report from Employer 68 Employer
FORM-14 Claim for Permanent Disablement Benefit 76(A) IP/Beneficiary
FORM-15 Claim for Dependent Benefit 80 IP/Beneficiary
FORM-16 Claim for periodical payment of Dependent Benefits 83(A) IP/Beneficiary
FORM-19 Claim for Maternity Benefit and notice of work 88, 89 & 91 IP/Beneficiary
FORM-20 Claim for Maternity Benefit after the death of an Insured Women leaving behind the child 89(A) IP/Beneficiary
FORM-22 Funeral Expenses Claim 95(E) Beneficiary
FORM-23 Life Certificate for Permanent Disablement Benefit 107 IP/Beneficiary
FORM-24 Declaration and Certificate for Dependents Benefit 107(A) IP/Beneficiary
 
FORM NO. SUBJECT TO BE USED BY
ESIC-32 Wage/Contributory record for disablement benefit Employer
ESIC-37 Certificate of re-employment/continuous employment Employer
ESIC-53 Application for change in particulars of Insured Persons regarding change of Branch Office/Dispensary IP/Beneficiary
ESIC-63 Declaration form regarding payment to the legal heir/representative of the deceased IP IP/Beneficiary
ESIC-71 Particulars of contribution in case Return of Contribution in respect of an IP not sent Employer
ESIC-72 Application for duplicate Identity Card IP/Beneficiary
ESIC-86 Certificate of Employment Employer
ESIC-105 Certificate of Entitlement Employer
ESIC-126 Certificate of continuous employment for Extended Medical and Sickness Benefit Employer
ESIC-142 Claim for conveyance allowance and/or compensation for loss of wages for an IP appeared before the medical board IP/Beneficiary
C-1,2 & 6 Proforma for Survey Register  
C-18, Actual, Interest, C-19, 20, 22 & 23, D-18 & D-19 Proformas  
C-2 to C-5 & C-7 to C-12 Proformas