ESI Claim Form (India)
Employees State Insurance Act 1948
EMPLOYEES STATE INSURANCE CORPORATION
Claim Form for Benefits under the Employees State Insurance Act 1948
1. INSURED PERSON DETAILS
Name of Insured Person: [IP Name]
Insurance Number (IP Number): [IP Number]
Aadhaar Number: [Aadhaar Number]
Residential Address: [IP Address]
Bank Account Number: [Bank Account Number]
Bank IFSC Code: [IFSC Code]
2. EMPLOYER / ESTABLISHMENT DETAILS
Employer Name: [Employer Name]
Employer Code Number: [Employer Code]
Establishment Address: [Employer Address]
3. CLAIM DETAILS
Nature of Benefit Claimed: [Benefit Type]
Period of Incapacity / Absence: From [Incapacity From Date] to [Incapacity To Date]
Average Daily Wage: [Average Daily Wage]
4. MEDICAL CERTIFICATE DETAILS
Insurance Medical Officer / IMP: [IMO Name]
ESIC Dispensary / Hospital: [Dispensary Name]
Medical Certificate Number: [Medical Certificate Number]
5. CONTRIBUTION DETAILS
Contribution Period: [Contribution Period] [Contribution Year]
Days for which contributions paid: [Days Contributed]
6. DECLARATION BY INSURED PERSON
I, [IP Name], hereby declare that the information furnished in this claim form is true and correct to the best of my knowledge and belief. I have not received any payment for the period of incapacity/absence claimed herein from any source other than as disclosed. I authorise the ESIC to transfer the benefit amount directly to my Aadhaar-linked bank account as provided above. I understand that any false declaration renders me liable to prosecution under the Employees State Insurance Act 1948.
7. EMPLOYER'S CERTIFICATE
Certified that [IP Name] (IP No. [IP Number]) was employed at our establishment (Code: [Employer Code]) and was on leave / absent from [Incapacity From Date] to [Incapacity To Date] for the reason claimed. The average daily wage stated above is correct and contributions have been paid for [Days Contributed] days in the contribution period [Contribution Period] [Contribution Year].
Employer's Name and Seal: ___________________________
Authorised Signatory: ___________________________
Date: ___________________________
Insured Person
________________
Signature
Employer (Authorised Signatory)
________________
Signature
What Is a ESI Claim Form (India)?
An ESI Claim Form in India supplies the facts and figures the authority requires so the matter can be processed, assessed or verified.
The legal framework governing the ESI Claim Form (India) in India draws on several key statutes and regulatory bodies. Under Indian law, the Indian Contract Act 1872 governs contractual obligations, with Section 10 setting essential requirements for valid agreements. The Companies Act 2013 regulates corporate entities through the Registrar of Companies (ROC) and Ministry of Corporate Affairs (MCA). The Industrial Disputes Act 1947 and state labour commissioners govern employment disputes. The Information Technology Act 2000 and IT (Reasonable Security Practices) Rules 2011 protect personal data. The Income Tax Act 1961 and Goods and Services Tax Act 2017 govern tax obligations through the Central Board of Direct Taxes (CBDT) and GST Council. Parties executing a ESI Claim Form (India) in India should confirm the document reflects current law, including any amendments enacted since the original drafting date. The Right to Information Act, 2005 sets the foundational requirements.
When Do You Need a ESI Claim Form (India)?
An ESI Claim Form is needed in several specific situations. When an insured person is unable to work due to sickness for more than 2 days and wishes to claim Sickness Benefit under Section 46(1)(a), the claim form must be filed through the employer after obtaining a sickness certificate from the Insurance Medical Officer. A claim is needed when a female insured employee is claiming Maternity Benefit under Section 50 for confinement, miscarriage, sickness arising from pregnancy, or premature birth, with benefit period ranging from 26 weeks to the prescribed maximum. When an insured person suffers an employment injury (accident at workplace or occupational disease) and seeks Temporary or Permanent Disablement Benefit under Section 51, the claim must be filed after the employer reports the accident in Form 16 to the Branch Office within 24 hours. Dependants of a deceased insured person need to file a claim for Dependants' Benefit when death results from an employment injury under Section 52, with a widow's benefit at 3/5th of the benefit rate and children's benefit at 2/5th. Extended Sickness Benefit claims are needed when the IP suffers from any of the 34 long-term specified diseases (TB, cancer, mental illness, etc.) listed under the ESI (Central) Rules, requiring a Medical Board certificate. Claims for Enhanced Sickness Benefit are needed by insured persons who have undergone sterilisation operations. The form is also required when claiming the ₹15,000 funeral expenses benefit under Regulation 95A for the nominee of a deceased insured person.
Parties in India should prepare a ESI Claim Form (India) proactively rather than waiting for a dispute to arise. Courts interpret agreements based on the written terms rather than oral representations. Under Indian law, the Indian Contract Act 1872 governs contractual obligations, with Section 10 setting essential requirements for valid agreements. The Companies Act 2013 regulates corporate entities through the Registrar of Companies (ROC) and Ministry of Corporate Affairs (MCA). The Industrial Disputes Act 1947 and state labour commissioners govern employment disputes. The Information Technology Act 2000 and IT (Reasonable Security Practices) Rules 2011 protect personal data. The Income Tax Act 1961 and Goods and Services Tax Act 2017 govern tax obligations through the Central Board of Direct Taxes (CBDT) and GST Council. Where the transaction involves regulated activities, prior approval from the relevant authority may be required before execution.
What to Include in Your ESI Claim Form (India)
An ESI Claim Form for India should contain the following key elements. The Insured Person's particulars: full name, Insurance Number (IP number assigned by ESIC), employer's code number, name and address of the establishment, designation, date of joining, and Aadhaar number for identity verification and direct benefit transfer. The nature of benefit claimed must be clearly stated: Sickness Benefit, Extended Sickness Benefit, Enhanced Sickness Benefit, Maternity Benefit, Temporary Disablement Benefit, Permanent Disablement Benefit, Dependants' Benefit, or Funeral Expenses. The period of incapacity or absence from work with exact dates of commencement and expected duration certified by the authorised IMO or IMP on a separate certificate form. Wage details including the average daily wage calculated over the relevant contribution period, and confirmation that the IP has paid contributions for at least the prescribed number of days (78 days for sickness benefit). The employer's certification of wages, absence record, and employment status, with the authorised signatory's name, designation, and seal. Bank account details including account number, bank name, branch, and IFSC code for Direct Benefit Transfer through the ESIC online portal. The claim form must be countersigned by the employer and submitted to the jurisdictional ESIC Branch Office. Declaration by the insured person that the information furnished is true and correct, with the IP's signature or thumb impression. Any supporting documents (medical certificate, wage certificate, birth/death certificate for dependants' claims) should be attached as per the claim type.
Additional compliance elements for a ESI Claim Form (India) used in India include: Under Indian law, the Indian Contract Act 1872 governs contractual obligations, with Section 10 setting essential requirements for valid agreements. The Companies Act 2013 regulates corporate entities through the Registrar of Companies (ROC) and Ministry of Corporate Affairs (MCA). The Industrial Disputes Act 1947 and state labour commissioners govern employment disputes. The Information Technology Act 2000 and IT (Reasonable Security Practices) Rules 2011 protect personal data. The Income Tax Act 1961 and Goods and Services Tax Act 2017 govern tax obligations through the Central Board of Direct Taxes (CBDT) and GST Council. Forms-legal.com provides this template as a starting point for India-compliant documentation.
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Reference this free template in an article, syllabus, or research note:
Forms Legal. (2026). ESI Claim Form (India) (India) [Legal document template]. Forms Legal. https://forms-legal.com/india/government/social-security/esi-claim-form-india
"ESI Claim Form (India) (India)." Forms Legal, 2026, https://forms-legal.com/india/government/social-security/esi-claim-form-india.
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author = {{Forms Legal}},
title = {ESI Claim Form (India) (India)},
year = {2026},
howpublished = {\url{https://forms-legal.com/india/government/social-security/esi-claim-form-india}},
note = {Free legal document template. Based on Right to Information Act, 2005}
}Frequently Asked Questions
Eligibility to file an ESI claim in India is governed by the Employees State Insurance Act 1948 and the ESI (Central) Rules 1950. An insured person (IP) is eligible to claim benefits if they are employed in a factory or establishment covered under the Act and earn wages not exceeding the statutory wage ceiling (currently ₹21,000 per month, or ₹25,000 for persons with disability). The IP must have contributed to the ESI fund for the prescribed contribution period — generally at least 78 days' contribution in the immediately preceding two contribution periods for sickness benefit under Section 46(1)(a), or 70 days for maternity benefit under Section 50 read with Regulation 56. For disablement benefit under Section 51, contributions are not required as the benefit accrues from the first day of insurable employment. Dependants of a deceased insured person are entitled to dependants' benefit under Section 52 if the death occurred due to an employment injury. The IP must obtain a certificate of incapacity from an authorised Insurance Medical Officer or Insurance Medical Practitioner under Regulation 52 to validate the claim. Claims must be submitted to the concerned Branch Office of ESIC along with the claim form, medical certificate, wage certificate, identity proof, and bank passbook copy for direct benefit transfer under the Aadhar-linked payment system.
The Employees State Insurance Act 1948 provides a comprehensive social security net through six primary categories of benefits. Sickness Benefit under Section 46(1)(a) provides cash compensation at 70% of average daily wages for up to 91 days in two consecutive benefit periods during certified sickness. Extended Sickness Benefit is available for 34 specified long-term diseases for up to 2 years at 80% of wages. Enhanced Sickness Benefit at 100% wages for 7–14 days is available for ESI-covered persons who undergo family welfare operations (sterilisation). Maternity Benefit under Section 50 provides cash at 100% of average daily wages for 26 weeks for confinement, 6 weeks for miscarriage, and additional medical bonus. Disablement Benefit under Section 51 provides Temporary Disablement Benefit at 90% of wages for the duration of temporary disablement from employment injury, and Permanent Disablement Benefit as a periodic payment based on the degree of permanent loss of earning capacity assessed by a Medical Board. Dependants' Benefit under Section 52 provides periodic payments to dependants of insured persons who die due to employment injury, distributed among widow, children, and dependent parents. Medical Benefit under Section 46(1)(b) provides full medical care to insured persons and their families through ESIC hospitals, dispensaries, and panel clinics. Other benefits include Funeral Expenses under Regulation 95A (currently ₹15,000), Unemployment Allowance under the Rajiv Gandhi Shramik Kalyan Yojana, and Rehabilitation Allowance for those under vocational rehabilitation.
The ESI claim submission process involves several steps under the Employees State Insurance (General) Regulations 1950. First, the insured person must obtain a Certificate of Sickness or Incapacity from an authorised Insurance Medical Officer (IMO) or Insurance Medical Practitioner (IMP) in the prescribed form (Form 9 for sickness, Form 21 for maternity, Form 16 for disablement). The employer must certify the wage details on the claim form, confirming the average daily wage and the contribution period compliance. The completed claim form must be submitted to the ESIC Branch Office having jurisdiction over the insured person's place of employment, along with supporting documents including: the insured person's IP number proof (ESIC card or Pehchan card), Aadhaar card for identity verification, bank account passbook with IFSC code for Direct Benefit Transfer, wage certificate from the employer confirming the last 12 months' contributions, leave or absence record from the employer, and medical certificate from the authorised IMO or IMP. For maternity claims, an ante-natal certificate and confinement certificate or medical termination certificate are required. For disablement claims, the accident report (Form 16) must be filed by the employer within 24 hours under Regulation 68, and the Medical Board assessment certificate is needed for permanent disablement. Claims must generally be filed within 12 months of the end of the benefit period under Regulation 49, though ESIC has discretion to condone delays.
A ESI Claim Form (India) does not legally require a lawyer in India, and individuals and businesses may draft and execute the document independently. The Right to Information Act, 2005 does not mandate legal representation for the creation or signing of this type of document. However, seeking independent legal advice from a qualified India lawyer is recommended for transactions involving substantial financial value, complex regulatory requirements, or cross-border elements where multiple legal jurisdictions may apply. A lawyer can verify that the document complies with all applicable statutory requirements, identify potential risks specific to the transaction, and confirm that the terms adequately protect the interests of all parties involved. The Supreme Court of India has jurisdiction over disputes arising from this type of document, and Registrar of Companies (ROC) may impose additional compliance obligations depending on the nature of the underlying transaction. Professional legal review is particularly advisable where the document will be submitted to government agencies or used as evidence in legal proceedings.
A ESI Claim Form (India) does not legally require a lawyer in India, though legal advice is recommended. Under Indian law, the Indian Contract Act 1872 governs agreements. The Companies Act 2013 and Registrar of Companies (ROC) regulate corporate documents. The Information Technology Act 2000 governs electronic contracts and data protection. The Consumer Protection Act 2019 provides consumer rights. The Income Tax Act 1961 requires tax compliance. Forms-legal.com provides this template as a starting point — always review with a qualified Indian advocate for significant transactions. Under India law, Right to Information Act, 2005, parties should seek independent legal advice from a qualified lawyer to confirm compliance with all applicable requirements. Under Indian law, the Indian Contract Act 1872 governs contractual obligations, with Section 10 setting essential requirements for valid agreements. The Companies Act 2013 regulates corporate entities through the Registrar of Companies (ROC) and Ministry of Corporate Affairs (MCA). Forms-legal.com provides this template as a starting point for India-compliant documentation.
This template is provided for informational purposes only and does not constitute legal advice. Laws vary by jurisdiction and change over time. Consult a qualified attorney for advice specific to your situation.Full disclaimer
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