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