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ESIC-105 Employees' State Insurance Corporation Certificate of Entitlement

The document contains two certificates. The first is a Certificate of Entitlement that certifies an employee's insurance details and confirms they are proceeding on authorized leave or temporary duty from one location to another for a specified period. The second is an Application for Medical Treatment as a Temporary Resident where an insured employee applies for medical treatment at a dispensary while on authorized leave or temporary duty away from their usual place of work for a specified period. The doctor accepts the person onto their patient list.

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23K views2 pages

ESIC-105 Employees' State Insurance Corporation Certificate of Entitlement

The document contains two certificates. The first is a Certificate of Entitlement that certifies an employee's insurance details and confirms they are proceeding on authorized leave or temporary duty from one location to another for a specified period. The second is an Application for Medical Treatment as a Temporary Resident where an insured employee applies for medical treatment at a dispensary while on authorized leave or temporary duty away from their usual place of work for a specified period. The doctor accepts the person onto their patient list.

Uploaded by

Industrial Security Agency
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ESIC-105

Employees’ State Insurance Corporation

Certificate of entitlement

Name & Address of Employer: Code No.

Certified that shri ……………………………………………………………………..S/W/D of………………………………………

Insurance No…………………………………………………………………

Whose identification/marks and Signature/ thumb impression are given below, is in our employment
and contributions are being paid in respect of him/her.

He/she is proceeding to from………………………………to……………………………..on the authorized

Leave/temporary duty for the period

Identification mark of the Ins. person

Signature…………………………….

Signature/thumb impression Designation

Date……………………………………

Form 10

ESIC-MED 10

APPLICATION FOR MEDICAL TREATMENT AS TEMPORARY RESIDENT

I………………………………………… S/W/D of ………………………………….. Insurance No ……………………….............

Employee of ……………………………………………………………… having come to (place) on authorized

Leave/• temporary duty, hereby apply for acceptance by • Dr……………………………………………………………

……………………………………………. (Dispensary) I propose to stay here from ……………………to……………………

Date …………………………………………

I accept this person on my list. Signature or thumb impression


of the insured person
Code No. Stamp of ………………. Dispensary
Signature of Doctor • Delete whichever not applicable Date………………

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