| Schedule III |
Regulation 76-B: Commutation Values for Permanent Disablement Benefit |
Schedule |
| Form 01 |
Regulation 10-B :Employer’s Registration Form |
Form |
| Form 01A |
Regulation 10-C: Form of Annual Information of Factory/Establishment covered under the ESI Act |
Form |
| Form I |
Regulation 11 & 12 : Employee Declaration Form |
Form |
| Form I-A |
Regulation 15-A : Family Declaration Form |
Form |
| Form 2 |
Regulation 15-B : Changes in Family Declaration Form (Old Form 1-B) |
Form |
| Form 3 |
Regulation 14 : Return of Declaration Forms |
Form |
| Form 4 |
Regulation 17, 95-A: Identity Card |
Form |
| Form 4-A |
Regulation 95-A(4) : Family Identity Card |
Form |
| Form 5 |
Regulation 26 : Return of Contributions (Old Form 6) |
Form |
| Form 5-A |
Regulation 31 Proviso 2: Statement of Advance Payment of Contributions (Old Form 6-A) |
Form |
| Form 6 |
Regulation 32 : Register of Employees (Old Form 7) |
Form |
| Form 7 |
Regulation 57, 58, 59: First Medical Certificate (Old Forms 8,9,10) |
Form |
| Form 8 |
Regulation 61 & 89-B : Special Intermediate Certificate (Old Form 11) |
Form |
| Form 9 |
Regulation 63 & 89-B: Claim Form for Sickness Or Temporary Disablement Benefit or Maternity Benefit (Old Forms 12-14A) |
Form |
| Form 10 |
Regulation 52-A: Confirmation of Incapacitation of Employee (Old Form 28A) |
Form |
| Form 11 |
Regulation 66 : Accident Book (Old Form 15) |
Form |
| Form 12 |
Regulation 68 : Accident Report From Employer (Old Form 16) |
Form |
| Form 13 |
Regulation 79 and 95-C : Death Certificate (Old Form 17) |
Form |
| Form 14 |
Regulation 76-A : Claim for Permanent Disablement Benefit (Old Form 25) |
Form |
| Form 15 |
Regulation 80 : Dependants Benefit - Claim Form (Old Form 18) |
Form |
| Form 16 |
Regulation 83-A : Defendants Benefit/ Claim Form for periodical payments (Old Form 18-A) |
Form |
| Form 17 |
Regulation 87 : Certificate/Notice of Pregnancy (Old Forms 19/20) |
Form |
| Form 18 |
Regulation 88 & 89 : Certificate of Expected Confinement/Confinement/Miscarriage ((Old Forms 21/23) |
Form |
| Form 22 |
Regulation 88, 89 & 91 : Claim for Maternity Benefit and Notice of Work (Old Forms 22 and 24) |
Form |
| Form 20 |
Regulation 89-A : Maternity Benefit Claim After The Death Of An Insured Woman Leaving Behind The Child (Old Form 24-A) |
Form |
| Form 21 |
Regulation 89-A : Maternity Benefit Death Certificate (Old Form 24-B) |
Form |
| Form 22 |
Regulation 95-E : Funeral Expenses Claim Form (Old Form 25-A) |
Form |
| Form 23 |
Regulation 107 : Certificate for Permanent Disablement Benefit (Old Form 26) |
Form |
| Form 24 |
Regulation 107-A : Declaration and Certificate for Dependants’ Benefit (Old Form 27) |
Form |
