FORM CR-1
PROFORMA SEEKING RECTIFICATION OF CONTRIBUTION REMITTED UNDER A WRONG
INSURANCE NUMBER
PART- A
(TO BE FILLED BY THE APPLICANT EMPLOYER)
Request From:
Employer Name :
Code No. :
1. Original Number allotted to the Employee :
(Based on Manual Declaration Form)
2. Wrong Number under which contribution has :
been / is being remitted wrongly
3. From which month the wrong remittance had :
started
4. Until which month it has been remitted ( Please :
attach month wise wage / contribution details)
5. Whether Pehchan Card obtained : YES / NO
6. If yes, under which insurance number :
(Please attach copy of Pehchan card & TIC/PIC)
We request to kindly transfer the contribution wrongly remitted by us back to correct Insurance Number as
given in serial no.1 above
We also herewith enclose the following under the Company Letter Head & Seal.
a) Month wise statement as given in Point nos. 3 & 4.
b) Written statement assuring that such mistakes would not be repeated in future.
Date: Name of the Employer:
Designation & Seal:
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PART- B
BRANCH MANAGERS REPORT ON APPLICANT’S INSURANCE NUMBER
1. Employee’s Original Insurance Number (10 digit) :
2. Employee’s wrong Insurance No.(10 digit)
3. Whether both the numbers belong to the same : YES / NO
Employer
4. If No, Employer of wrongly remitted number :
(Name/Code/BO to which it is attached)
5. Whether name of the IP, under both the : YES / NO
numbers/TICS are same?
6. Whether data under the fields other than the : YES / NO
“name” in the TIC are also same?
7. Whether the correctness of wage particulars has :
been confirmed with the wage records of the
applicant ? (Enclose details)
[If point No. 5 & 6 is ‘Yes’, then the employer has edited the names and other details online (under
update IP details tab which was editable earlier). The applicant-employer has replaced the data of the
actual card-holder with that of his employee. Hence, in such cases condonation letter is to be invariably
obtained from the applicant-employer].
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PART -C
BM’S REPORT ON INSURANCE NUMBER TO WHICH THE CONTRIBUTION WAS MISTAKENLY
REMITTED
1. Based on Manual Declaration Form, what is the :
name of the IP who was originally, allotted the
wrongly remitted insurance number.
2. Employer Details of that IP (as per Manual DF)
Name :
Code (17 Digit) :
3. Employee Service Details
Whether presently in Service : Yes / No
If No, Date of Leaving :
If Yes, Date of entry into insurable Employment :
Length of Service as on date :
4. Whether Pehchan Card has been obtained : Yes/ No
(under that number)
5. Any other remarks :
Signature of the Employer/ Branch Manager
(Seal)
[If the Employee under Part-C had left service, and if there is no intersection (overlapping) between the
periods of his service with that of the Applicant’s request period in Part A then the Branch Manager can
straight away recommend the case for transfer after verification of Applicant’s wage records . However, if
there is an overlapping / Intersection, in the service periods, then the details of the segregated wages of
both the IPs concerned are to be obtained from the IP Portal and reconcile it to avoid conflict later.]
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PART –D
(TO BE FILLED BY THE BRANCH MANAGER)
Recommendation of the Branch Manager
The Application has been verified with the records as well as with the other Employer and found correct.
Hence Regional Office (RO) may transfer the contributions as detailed below.
Field From To
Insurance No.
For the month
Remarks:
………………………………………………………………………………………
………………………………………………………………………………………
(Signature of Branch Manager)/Seal
ENCLOSURES FROM APPLICANT
1. Copy of Pehchan.
2. Copy of TIC.
3. Month wise salary/ contribution statement for the wrongly remitted period.
4. Assurance letter from Employer stating such mistakes would not be repeated again in future.
5. Condonation letter in company Letter pad signed by authorized signatory with
name/designation/phone; (optional).
ENCLOSURES FROM BRANCH MANAGER
1. Copy of the Manual Declaration Form (DF)
2. Month-wise salary statement signed by the applicant employer; to be verified and also
countersigned by Branch Manager with remarks “verified found correct”.
3. In case of overlap of service period between the 2 IPs segregated wage statement certified by the
BM.
NOTE:
1. Part A to be filled by the Applicant - Pertains to details submitted by the applicant.
2. Part B to be filled by the Manager – Verification of details submitted by the applicant with the wage
records of the applicant.
3. Part C to be filled by the BM – Verification/ Segregation of wage details between the 2 IPs if
necessary.
4. Part D is the recommendation of the Manager regarding transfer.
To
The Regional Director (Benefits), RO, ESIC, CHENNAI-600 034.
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