EMPLOYEES' STATE INSURANCE CORPORATION, WEST BENGAL REGION

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FORM NO.	SUBJECT	RELEVANT REGULATION	TO BE USED BY
FORM-01	Employer's Registration Form	10 B	Employer
FORM-01(A)	Form of annual information on factory/establishment covered under ESI Act	10 C	Employer
FORM-1	Declaration Form	11 & 12	Employer
FORM-1(A)	Family Declaration Form	15-A	Employer
FORM-2	Addition/Deletion in Family Declaration Form	15-B	Employer
FORM-3	Return of Declaration Form	14	Employer
FORM-5	Return of Contribution	26	Employer
FORM-5(A)	Advance payment of contribution	31	Employer
FORM-5 (New)	Return of Contribution (New)	31	Employer
FORM-6	Register of Employees	32	Employer
FORM-9	Claim for Sickness/ Temporary Disablement Benefit/Maternity Benefit	63 & 89(B)	IP/Beneficiary
FORM-11	Accident Book	66	Employer
FORM-12	Accident Report from Employer	68	Employer
FORM-14	Claim for Permanent Disablement Benefit	76(a)	IP/Beneficiary
FORM-15	Claim for Dependent Benefit	80	IP/Beneficiary
FORM-16	Claim for periodical payment of Dependent Benefits	83(A)	IP/Beneficiary
FORM-19	Claim for Maternity Benefit and notice of work	88, 89 & 91	IP/Beneficiary
FORM-20	Claim for Maternity Benefit after the death of an Insured Women leaving behind the child	89(A)	IP/Beneficiary
FORM-22	Funeral Expenses Claim	95(E)	Beneficiary
FORM-23	Life Certificate for Permanent Disablement Benefit	107	IP/Beneficiary
FORM-24	Declaration and Certificate for Dependents Benefit	107(A)	IP/Beneficiary
ESIC-32	Wage/Contributory record for disablement benefit		Employer
ESIC-37	Certificate of re-employment/continuous employmen		Employer
ESIC-53	Application for change in particulars of Insured Persons regarding change of Branch Office/Dispensary		IP/Beneficiary
ESIC-63	Declaration form regarding payment to the legal heir/representative of the deceased IP		IP/Beneficiary
ESIC-71	Particulars of contribution in case Return of Contribution in respect of an IP not sent		Employer
ESIC-72	Application for duplicate Identity Card		IP/Beneficiary
ESIC-86	Certificate of Employment		Employer
ESIC-105	Certificate of Entitlement		Employer
ESIC-126	Certificate of continuous employment for Extended Medical and Sickness Benefit		Employer
ESIC-142	Claim for conveyance allowance and/or compensation for loss of wages for an IP appeared before the medical board		Employer
C-1,2 & 6	Proforma for Survey Register		Employer