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ESIC Forms

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ESIC Forms Download

Under the Employees State Insurance (ESI) scheme, IPs or dependent family members will need to fill out and submit relevant forms available on the ESIC portal for making claims. 

Some of the forms include Form 23, Form 24, Form 72, Form 86, and so on.

The Employees' State Insurance Scheme (ESIC) is a health insurance scheme designed with the intent to protect the interests of workers in times of medical emergencies like

  • maternity, 
  • sickness,
  • permanent or temporary physical disablement,
  • employment-related death,
  • a temporary loss of one's physical abilities,
  • an occupationally-related death,
  • or an accident that results in a loss of income or the ability to earn. 

It is a social security scheme that is self-financed, where employers contribute 4.75% and employees contribute 1.75% of their wages.

The ESI scheme is run by the Employees' State Insurance Corporation, which is a separate body under the Ministry of Labour and Employment.

It follows the rules of the ESI Act of 1948. Employees who have a monthly salary of Rs. 21,000 or less are eligible to enrol in the Employees' State Insurance Scheme.

This scheme provides the following benefits to registered employees and their dependent family members:

  • Medical benefit
  • Maternity benefit
  • Sickness benefit
  • Pension benefit
  • Dependent benefit
  • Disablement benefit
  • Funeral and confinement expenses

How to Register for the ESI scheme?

The ESI plan needs any establishment or company that employs more than 10 employees to register for participation in the programme.

They are able to do so by entering the information that is needed through the ESIC portal, which can be accessed at www.esic.in.

In doing so, a code number comprising 17 digits is generated and sent to the email ID of the employer along with a registration form and the ESIC login credentials.

The employer can then log in using the credentials and fill in the mandatory information.

If the company runs into any problems while enrolling employees, they can send an email to the ESIC IT desk at the address itcare@esic.in.

Download ESIC Forms

For many conditions and critical situations registered employees or their dependent family members are required to fill out and submit various forms. These ESIC forms are available here to download for your convenience.

All ESIC Forms are listed below, download and use them as per your requirements.

No.

Form Purpose

Download

Form 01

Employer’s (Company / Firm Registration Form

Download

Form 1

Employee Declaration Form

Download

Form 1A

Family member Declaration Form

Download

Form 2

Addition / Deletion in Family Declaration Form

Download

Form 3

Return of Declaration Form

Download

Form 5

Return of Declaration Form (Half Yearly)

Download

Form 10

Claim for Sickness / Temporary Disable-ment Benefit / Maternity Benefit

Download

Form 11

Accident Book

Download

Form 12

Accident Report from Employer

Download

Form 14

Claim form for Permanent Disable-ment Benefit

Download

Form 15

Claim form for Dependent Benefit

Download

Form 16

Claim form for Periodical Payment of DB

Download

Form 19

Claim form for Maternity Benefit and Notice of Work

Download

Form 22

Claim for Funeral Expenses

Download

Form 24

Declaration and Certificate for Dependent Benefit

Download

ESIC 32

Wage Or - Record For Diablement Benefit

Download

ESIC 37

Certificate of Re-employ-ment or continuing Employ-ment

Download

ESIC 53

Application for change in particulars of Insured Persons (IPs)

Download

ESIC 63

Declaration form regarding payment to the legal heir of IP

Download

ESIC 71

Particulars of contribution in case RC in respect of an IP

Download

ESIC 86

Certificate for Employ-ment

Download

Dep-en-dency

Form of Certificate of Depen-dency

Download

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