How To Fill ESIC Maternity Claim Form 19 | Sample Filled ESIC Claim Form 19

Introduction

ESIC Maternity Claim Form 19 is an important document that needs to be filled and submitted to the Employees’ State Insurance Corporation (ESIC) for claiming maternity benefits. This form is used to claim maternity benefits for female employees who are insured under the Employees’ State Insurance Act, 1948. The form is to be filled by the insured female employee and submitted to the ESIC office along with the required documents. In this article, we will discuss how to fill ESIC Maternity Claim Form 19 and provide a sample filled ESIC Claim Form 19 for reference.

How To Fill ESIC Maternity Claim Form 19 | Sample Filled ESIC Claim Form 19

Step 1: Start by downloading the ESIC Maternity Claim Form 19 from the official website of the Employees’ State Insurance Corporation (ESIC).

Step 2: Fill in the details of the claimant such as name, address, date of birth, etc.

Step 3: Enter the details of the employer such as name, address, etc.

Step 4: Enter the details of the insured person such as name, date of birth, etc.

Step 5: Enter the details of the maternity benefit such as date of confinement, type of delivery, etc.

Step 6: Enter the details of the medical expenses incurred such as hospitalization charges, medicines, etc.

Step 7: Enter the details of the medical practitioner such as name, address, etc.

Step 8: Enter the details of the bank account where the payment is to be made.

Step 9: Attach the required documents such as medical bills, medical certificate, etc.

Step 10: Sign the form and submit it to the ESIC office.
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ESIC maternity claim form 19 is also known as the claim for maternity and notice of work.  ESIC claim form 19 has to be submitted to the employer by the insured pregnant woman in order to claim payment of maternity benefits. Under Employee State Insurance Corporation regulations 88, 89 and 91 ESIC form 19 is required to claim maternity benefits of employees. Here you can find complete details on how to fill ESIC maternity claim form 19 and you can also find sample filled ESIC claim form 19.

How To Fill ESIC Maternity Claim Form 19 | Sample Filled ESIC Claim Form 19

↓ Download ESIC Claim Form 19

ESIC self-declaration form related to maternity

ESIC Maternity Claim Form 19

You may also like: ESIC self-declaration form related to maternity

Why Should Insured Woman Submit ESIC Claim Form 19?

As we all know as per maternity benefits act 1961 every insured woman will get 26 weeks of maternity leaves during pregnancy time earlier it was only 12 weeks i.e employer needs to pay salary to the insured woman in these days. Along with this ESIC maternity claim form 19, the insured woman needs to submit ESIC self-declaration form related to maternity.

Note:  On ESIC claim form 19 insured woman need to mention the exact date from which date to which date she is availing maternity leaves.

ESIC maternity claim form consists details like name of the insured woman, ESIC IP number, the address of the pregnant woman, working department of the insured woman and present employer name.

The insured woman is not eligible to claim any leave encashment while availing maternity benefits. Any false representation of ESIC claim form leads to a fine of 2000 Rs.

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How To Fill ESIC Maternity Claim Form 19 | Sample Filled ESIC Claim Form 19

ESIC maternity claim form 19 is a form that is used to claim maternity benefits from the Employees’ State Insurance Corporation (ESIC). The form is used to claim maternity benefits for the period of 12 weeks before and 12 weeks after the expected date of delivery. The form is to be filled by the insured woman and submitted to the ESIC office along with the required documents.

Instructions to Fill ESIC Maternity Claim Form 19

  1. Enter the name of the insured woman in the first field.
  2. Enter the ESIC number of the insured woman in the second field.
  3. Enter the date of expected delivery in the third field.
  4. Enter the name of the employer in the fourth field.
  5. Enter the address of the employer in the fifth field.
  6. Enter the name of the establishment in the sixth field.
  7. Enter the address of the establishment in the seventh field.
  8. Enter the date of commencement of employment in the eighth field.
  9. Enter the date of termination of employment in the ninth field.
  10. Enter the period of maternity leave in the tenth field.
  11. Enter the amount of maternity benefit claimed in the eleventh field.
  12. Enter the name of the bank in the twelfth field.
  13. Enter the branch of the bank in the thirteenth field.
  14. Enter the account number in the fourteenth field.
  15. Enter the IFSC code of the bank in the fifteenth field.
  16. Enter the name of the doctor in the sixteenth field.
  17. Enter the address of the doctor in the seventeenth field.
  18. Enter the date of delivery in the eighteenth field.
  19. Enter the name of the hospital in the nineteenth field.
  20. Enter the address of the hospital in the twentieth field.
  21. Enter the date of admission in the twenty-first field.
  22. Enter the date of discharge in the twenty-second field.
  23. Enter the name of the guardian in the twenty-third field.
  24. Enter the address of the guardian in the twenty-fourth field.
  25. Enter the name of the witness in the twenty-fifth field.
  26. Enter the address of the witness in the twenty-sixth field.
  27. Enter the date of submission of the form in the twenty-seventh field.
  28. Enter the signature of the insured woman in the twenty-eighth field.

Sample Filled ESIC Claim Form 19

Name of the Insured Woman: Jane Doe
ESIC Number: 123456789
Date of Expected Delivery: 01/01/2021
Name of the Employer: ABC Corporation
Address of the Employer: 123 Main Street, Anytown, USA
Name of the Establishment: ABC Corporation
Address of the Establishment: 123 Main Street, Anytown, USA
Date of Commencement of Employment: 01/01/2020
Date of Termination of Employment: 01/01/2021
Period of Maternity Leave: 12 weeks before and 12 weeks after the expected date of delivery
Amount of Maternity Benefit Claimed: $1000
Name of the Bank: XYZ Bank
Branch of the Bank: Anytown Branch
Account Number: 123456789
IFSC Code of the Bank: XYZ12345
Name of the Doctor: Dr. John Smith
Address of the Doctor: 456 Main Street, Anytown, USA
Date of Delivery: 01/02/2021
Name of the Hospital: Anytown Hospital
Address of the Hospital: 789 Main Street, Anytown, USA
Date of Admission: 01/01/2021
Date of Discharge: 01/02/2021
Name of the Guardian: Jane Doe
Address of the Guardian: 123 Main Street, Anytown, USA
Name of the Witness: John Doe
Address of the Witness: 456 Main Street, Anytown, USA
Date of Submission of the Form: 01/03/2021
Signature of the Insured Woman: ___________________

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