ANNEXURE ‘A’
[See Para 12.A.5(1) & (2)]
Application for medical benefit under Rule 60/Rule 61 of the
ESI (Central) Rules, 1950
To
The Manager,
Branch Office,
…………………………………..
Sir,
*I
…………………………………………………….s/w/o……………………………………Ins.
No………………ceased to be in insurable employment with effect from
……………………with M/s ………………………………….. on account of permanent
disablement resulting from employment injury sustained by me on …………….
*I……………………………………………………….s/w/o……………………………
………Ins. No………………ceased to be in insurable employment with
M/s……………………………………. on my retirement on superannuation with effect from
……………………..
I am willing to avail of the medical benefit for myself and my spouse from the ESI
Dispensary ………………., at the scale prescribed by the Corporation/State Govt. for
permanently disabled/superannuated persons. I understand that I and my spouse will be entitled
to all reasonable medical care and treatment except super-speciality medical care and treatment
under the ESI Schme. I am also willing to deposit a sum of Rs. 120/- (Rupees one hundred and
twenty only) as contribution @ Rs. 10/- per month in lump sum for one year in advance, i. e., for
the period from …………………… to …………………… In support of my claim I enclose the
following :
i) Certificate from the employer.
ii) My declaration in prescribed form.
My present residential address is ………………………………………………………….
Yours faithfully,
Dated: (L. T. I./Signature of the applicant)
* Strike out which is not applicable
ANNEXURE ‘B’
[See Para 12.A.5(1)]
Certificate by Employer
[Under Rule 60 of the ESI (Central) Rules, 1950]
*Certified that Shri ……………………………… Ins. No.. ……………….. employed with us in
…………………….. (Deptt.) as …………………………………. (design.) sustained an employment injury on
………………………… He was examined by the Medical Board/MAT/E. I. Court on ………… ………………
(date). He has ceased to be in insurable employment of our factory/estt. M/s. ....................... .............. Code No.
........................ with effect from ………….solely on account of permanent disability suffered by him. His date of
birth as per our records is ……………………….. Had he not become disabled permanently on account of
employment injury sustained by him on ……………………, he would have continued in our employment till
attaining the age of superannuation, i. e., on ……………………. (date).
[Under Rule 61 of the ESI (Central) Rules, 1950]
*Certified that Shri ……………………………… Ins. No.. ………………..date of birth …………..
…………………… an employee of our factory/estt. M/s …………………….. Code No……………… has attained
the age of superannuation on …………………….. He has been superannuated as per factory’s/establishment’s
order no. …………………………… dated………………………….(copy enclosed).
He was an insured person under the Act from …………………………… to ……………………. The ESI
contributions paid in respect of him for the above period are detailed below.
C. P. ending No. of days Amount of cont. paid Sl. No. in R. C.
His contribution for C. P. ending …………………. (current C. P.) for …………………. days amounting to
Rs. ………………. is payable/has been already paid.
L. T. I./Signature of I. P. Signature and seal of the employer
or his agent.
*Strike out which is not applicable
ANNEXURE ‘C’
[See Para 12.A.5(1)]
Declaration of the Insured Person
[for medical benefit under Rule 60 of ESI (Central) Rules, 1950]
I ……………………………………….. Ins. No. ………………………. ceased to be in insurable
employment with effect from ……………………. on account of permanent disability caused to me due to
employment injury sustained by me on ……………………. I was examined by the Medical Board/Medical Appeal
Tribunal/EI Court on ……………….. and was awarded …………………. % disability finally, I was employed
with M/s……………………….. in …………………….. (Deptt.) as …………………. (designation). I would have
continued in insurable employment but for the permanent disability caused to me due to employment injury.
I solemnly declare and affirm that the particulars given above are true to the best of my knowledge and
belief and nothing has been concealed therefrom. If at any time these particulars are found to be false I and my
spouse may be disqualified for medical benefit and amount of contribution deposited by me may be forfeited.
T. I/Signature of I. P.
