Employee State Insurance Corporation Scheme (ESI) Forms

Under the Employees’ State Insurance (ESI) scheme, one will need to fill and submit relevant forms available on the ESIC portal for making claims. Some of the forms include Form 72, Form 23, Form 24, Form 15, and so on.

The Employees’ State Insurance (ESI) scheme is a health insurance scheme designed with an intent to protect the interests of workers in times of medical emergencies like maternity, sickness, permanent or temporary physical disablement, employment related death or injury leading to a loss in earnings or the capacity to earn. It is a social security scheme which is self-financed where employers contribute 4.75% and the employees contribute 1.75% of their wages.

The ESI scheme operates under the guidelines of the ESI Act, 1948 and is managed by the Employees’ State Insurance Corporation which is an autonomous body under the Ministry of Labour and Employment. The ESI scheme is meant for workers earning equal to or less than Rs.21,000 a month. Under this scheme, the below benefits are provided:

  • Medical benefit
  • Maternity benefit
  • Sickness benefit
  • Pension benefit
  • Dependent benefit
  • Disablement benefit
  • Funeral and confinement expenses

How to Register for the ESI scheme?

Establishments or firms that employ more than 10 people need to register under the ESI scheme. They can do so by logging into the ESIC portal - www.esic.in and submitting the requested information. On doing so, a code number comprising of 17 digits is generated and sent to the email ID of the employer along with a registration form and the ESIC login credentials. The employer can then login using the credentials and fill up the mandatory information. If there is any issue while registering, the employer can email the ESIC IT desk at itcare@esic.in.

Health Insurance Related Pages

What are ESI forms?

To make claims under the ESI scheme, the beneficiaries have to submit the relevant ESI forms after duly filling it. The form is available on the ESIC portal. Listed below are the details of the various ESI forms available:

Form 72 - This form is used to request for a duplicate ESIC smart card request.

Form 23 - This form is a life certificate form that is required to avail the permanent disablement benefit.

Form 24 - This form is a declaration and certificate for availing disablement benefit.

Form 22 - This form is used for making a claim for funeral expenses.

Form 20 - This form can be used for availing maternity benefits after the death of the insured person.

Form 19 - In order to claim maternity benefits and notice of work, this form has to be submitted.

Form 16 - For making claims for periodical payment of disablement benefit, this form can be used.

Form 15 - This is a form used for making claims for availing dependent benefits.

Form 14 - This is a claim form for permanent disability benefit.

Form 12 - This is an accident report form from the employer.

Form 11 - Accident book.

Form 9 - This form is used for making claims for sickness, temporary disablement benefit, and maternity benefit.

Form 6 - This a register of the employees.

Form 5A - If any beneficiary wishes to make an advance payment for his/her contribution, he/she can do so by submitting this form.

Form 5 - This form is used to return contributions made by the employee.

Form 3 - This is a form for return of declaration.

Form 2 - To make changes in the declaration form, form 2 is used.

Form 1 - This is a declaration form.

Form 01 - Employer’s registration form.

Form 1A - Family declaration form.

Form 142 - This form is used for making claims for compensation for loss of earnings and conveyance allowance.

Form 105 -Certificate of entitlement.

Form 86 - Certificate of employment.

Form 63 - Declaration form with regards to payment to the legal heir.

Form 53 - Application form for change in particulars of insured person.

Form 37 - Certificate of re-employment or continuous employment.

Form 32 - Wage-contributory record for disablement benefit.

All of the above-mentioned ESI forms are available to download from the ESIC portal and can be used for making claims under the Employees’ State Insurance scheme.

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