[***]

104 [ 109 Submission of additional information by employer or in­sured person. -The employer or insured person, as the case may be, shall, on demand from the appropriate Office, submit informa­tion in such form as may be specified by the Director-General.]

THE EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS, 1950 1[FORM 10 Abstention verification in respect of sickness benefit/ temporary disablement benefit/maternity benefit [Regulation 52A (1) and (2)] Confidential Empployees’ state insurance corporation From: The Manager ...........Branch Office, E.S.I., Corporation, To M/s.......................................................................... .................................................................................. Subject:—Verification of abstention from work in respect of Sh./Smt./ Km..................................................... Ins. No......................... Department................................. Dear Sir(s) The above named employee of your factory has submitted a certifi­cate of incapacity for the period from....................... to......................... and has declared that he/she has not worked on any day during this period. He/she has further declared that he/she has not received wages as defined under section 2(22) of ESI Act, 1948 for any leave/holiday/weekly off/lay off and strike in respect of any day during the above period and that he/she was not on strike on any day during the above period. I shall be grateful if you confirm the exact position, in this regard, on the Form, appended within 10 days of the receipt of this Form. Yours faithfully, (Manager) ..........................Branch office REPLY TO BE FURNISHED BY THE EMPLOYER IN RESPECT OF FORM NO. 10 Name of the Insured Person/Insured Woman......................................... Insurance No.......................................... Returned with the remarks that the employee in question has not worked on any day during the period from.................... to....................or* that he/she has worked on ........................................ during the period from.......................... to.................... 1. It is further confirmed that— (a) He/she remained on leave with wages for the period from....................... to.................... (b) He/she remained on holidays with wages from.............. to.................... (c) He/she was on weekly off with wages for.............................................. (d) He/she was on lay-off with wages from.............. to.................... (e) He/she was on strike from.............. to.................... 2. In case, the IP/IW is paid any wages for any of the days falling during the above- mentioned period subsequently, the same will be notified to you in due course. 3. The day proceeding the first day of absence was*/was not a holiday for the Insured Person/Insured Woman. Date.................. Signature.................................................... Name in block letters and Designation.......................... .................................................................. Code No.................................................... * Strike out which is not applicable] ————— 1. Subs. by Notification No. N-11/13/2/2003-P&D, dated 1st October, 2004, for Forms 28 and 28A (w.e.f. 1-1-2005). THE EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS, 1950 1[FORM 9 Claim for SICKNESS/T.D.B./MATERNITY BENEFIT FOR SICKNESS (Regulations 63 and 89B) Employees’ state insurance corporation (i)* That because of sickness/temporary disablement/sickness due to pregnancy/confinement/premature birth of child/miscarriage, I have not been at work since ........................... (ii)* I no longer claim to be sick/temporary disabled/sick due to pregnancy/confinement/premature birth of child/miscarriage from ............... and I shall/did not take up any work for remuneration before that date. (iii)* I have not been in receipt of any wages for the days of leave/holiday(s). (iv)* I was not on strike during the period of certified abstention on account of sickness/temporary disablement i.e. from ......................... to ......................... for which the benefit is claimed. I desire payment in *cash at Branch Office/By Money Order. Signature or T.I. of claimant Name in Block Letters.................................... Address......................................................... ...................................................................... Notes.— 1. Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself/some other person shall be punishble with imprisonment up to 6 months or fine up to Rs. 2000 or both. 2. This form should be completed and submitted WITHOUT DELAY to the appropriate Branch Office. 3. A final certificate must be obtained before resuming work. * Strike out if not applicable] ————— 1. Subs. by Notification No. N-11/13/2/2003-P&D, dated 1st October, 2004, for Forms 12, 12A, 13, 13A, 14 and 14A (w.e.f. 1-1-2005). THE EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS, 1950 1[*] ————— 1. Schedule I omitted by Notification No. N-12/13/1/90-P&D, dated 17th May, 1991 (w.e.f. 15-6-1991). THE EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS, 1950 1[*] ————— 1. Schedule II omitted by Notification No. N-12/13/1/90-P&D, dated 17th May, 1991 (w.e.f. 15-6-1991).