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    Employees' State Insurance Corporation: WWW - Esickar.gov - in

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    Satish Tiwari
    This document is a verification form sent by an Employees' State Insurance Corporation branch manager to an employer to confirm periods of absence from work for an insured employee seeking sickness benefits. It requests confirmation that the employee did not work or receive wages during the stated period and was not on strike. The employer must respond within 10 days using the attached reply form to verify this or report any days worked/wages received. It also requests clarification on any leave or holidays for days in the period.

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    Employees' State Insurance Corporation: WWW - Esickar.gov - in

    Uploaded by

    Satish Tiwari
    104 views2 pages
    This document is a verification form sent by an Employees' State Insurance Corporation branch manager to an employer to confirm periods of absence from work for an insured employee seeking sickness benefits. It requests confirmation that the employee did not work or receive wages during the stated period and was not on strike. The employer must respond within 10 days using the attached reply form to verify this or report any days worked/wages received. It also requests clarification on any leave or holidays for days in the period.

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    This document is a verification form sent by an Employees' State Insurance Corporation branch manager to an employer to confirm periods of absence from work for an insured employee seeking sickness benefits. It requests confirmation that the employee did not work or receive wages during the stated period and was not on strike. The employer must respond within 10 days using the attached reply form to verify this or report any days worked/wages received. It also requests clarification on any leave or holidays for days in the period.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    104 views2 pages

    Employees' State Insurance Corporation: WWW - Esickar.gov - in

    Uploaded by

    Satish Tiwari
    This document is a verification form sent by an Employees' State Insurance Corporation branch manager to an employer to confirm periods of absence from work for an insured employee seeking sickness benefits. It requests confirmation that the employee did not work or receive wages during the stated period and was not on strike. The employer must respond within 10 days using the attached reply form to verify this or report any days worked/wages received. It also requests clarification on any leave or holidays for days in the period.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    www.esickar.gov.

    in

    EMPLOYEES’ STATE INSURANCE CORPORATION


    REG. FORM- 10
    CONFIDENTIAL

    ABSTENTION VERIFICATION IN RESPECT OF SICKNESS BENEFIT/


    TEMPORARY DISABLEMENT BENEFIT / MATERNITY BENEFIT
    (Regulation 52-A)

    From :
    The Manager
    __________________ Branch Office,
    E.S.I. Corporation,
    __________________

    To :

    M/s _____________________________
    ________________________________
    ________________________________

    Subject: Verification of abstention from work in respect of Shri/Smt./Kum _____________


    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 the above 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
    www.esickar.gov.in

    EMPLOYEES’ STATE INSURANCE CORPORATION


    CONFIDENTIAL

    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 ____________________

    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 _______________________to ________________
    (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 Women.

    Date: ____________ Signature _________________________


    Name in block letter & Designation ______________________
    Code No. __________________________

    * Strike out if not applicable

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