Introduction
ESIC Form 10 is an important document that is used by the Employees’ State Insurance Corporation (ESIC) to register an employee for the Employees’ State Insurance Scheme. This form is used to provide the employee with medical and other benefits under the scheme. It is important for employers to fill out this form accurately and submit it to the ESIC office in order to ensure that the employee is registered for the scheme. This article will provide a step-by-step guide on how to fill out the ESIC Form 10. It will also provide a sample filled ESIC Form 10 for reference.
Sample Filled ESIC Form 10, How To Fill ESIC Form 10
1. Enter the name of the employer in the first field.
2. Enter the address of the employer in the second field.
3. Enter the name of the employee in the third field.
4. Enter the address of the employee in the fourth field.
5. Enter the date of joining of the employee in the fifth field.
6. Enter the date of leaving of the employee in the sixth field.
7. Enter the total number of days worked by the employee in the seventh field.
8. Enter the total wages paid to the employee in the eighth field.
9. Enter the total amount of contribution due from the employer in the ninth field.
10. Enter the total amount of contribution due from the employee in the tenth field.
11. Enter the total amount of contribution due from the employer and employee in the eleventh field.
12. Enter the date of payment of the contribution in the twelfth field.
13. Enter the name of the bank in which the contribution is to be deposited in the thirteenth field.
14. Enter the account number of the bank in which the contribution is to be deposited in the fourteenth field.
15. Enter the signature of the employer in the fifteenth field.
16. Enter the date of signing in the sixteenth field.
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ESIC Form 10 also know as Absenteeism verification form. It has to be filled by the employer and submitted to ESIC officer in order to claim sickness benefit of employees. Simply ESIC form 10 will be used when an insured person couldn’t able to attend his job when he had a medical problem and takes treatment from ESI hospitals.Here you can find complete details about how to fill ESIC form 10 and you can also download sample filled ESIC form 10.
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In ESIC form 10 employer needs to confirm ESIC officer that a particular insured person is absent or present in the period mentioned in the front page of ESIC form 10. The front page of ESIC form 10 will be filled by ESIC officials. For that employer needs to confirm whether the dates mentioned in front page or correct or not. This details have to be confirmed in second page by the employer.
Sample Filled ESIC Form 10 / How To Fill ESIC Form 10
Note : There is no need to fill 1 pg of ESIC Form 10, it has to be filled by ESIC officer. Here employer need to fill second page only.
↓ Download Filled ESIC Form 10
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How To Fill ESIC Form 10
ESIC Form 10 is an important document for employees who are covered under the Employees’ State Insurance Corporation (ESIC). It is a declaration form that needs to be filled by the employer and submitted to the ESIC office. The form is used to declare the details of the employees who are covered under the ESIC scheme. It is important to fill the form accurately and submit it on time to ensure that the employees are able to avail the benefits of the scheme.
Steps to Fill ESIC Form 10
- The employer needs to fill in the details of the employees who are covered under the ESIC scheme. This includes the name, address, date of birth, gender, and other details of the employee.
- The employer needs to provide the details of the employer such as the name, address, and contact details.
- The employer needs to provide the details of the establishment such as the name, address, and contact details.
- The employer needs to provide the details of the insurance policy such as the policy number, date of commencement, and date of expiry.
- The employer needs to provide the details of the contribution such as the amount of contribution, the period of contribution, and the date of payment.
- The employer needs to provide the details of the benefits such as the amount of benefits, the period of benefits, and the date of payment.
- The employer needs to provide the details of the medical facilities such as the type of medical facilities, the period of medical facilities, and the date of payment.
- The employer needs to provide the details of the other benefits such as the type of benefits, the period of benefits, and the date of payment.
- The employer needs to provide the details of the other deductions such as the type of deductions, the period of deductions, and the date of payment.
- The employer needs to provide the details of the other contributions such as the type of contributions, the period of contributions, and the date of payment.
- The employer needs to provide the details of the other expenses such as the type of expenses, the period of expenses, and the date of payment.
- The employer needs to provide the details of the other documents such as the type of documents, the period of documents, and the date of submission.
- The employer needs to provide the signature of the employer and the date of submission.
Sample Filled ESIC Form 10
The following is a sample filled ESIC Form 10:
Employee Name: John Doe
Employee Address: 123 Main Street, Anytown, USA
Employee Date of Birth: 01/01/1980
Employee Gender: Male
Employee ESIC Number: 123456789
Employer Name: ABC Corporation
Employer Address: 456 Main Street, Anytown, USA
Employer Contact Details: (123) 456-7890
Establishment Name: ABC Corporation
Establishment Address: 456 Main Street, Anytown, USA
Establishment Contact Details: (123) 456-7890
Insurance Policy Number: 123456789
Date of Commencement: 01/01/2020
Date of Expiry: 01/01/2021
Contribution Amount: $100
Period of Contribution: 01/01/2020 to 01/01/2021
Date of Payment: 01/01/2021
Benefits Amount: $200
Period of Benefits: 01/01/2020 to 01/01/2021
Date of Payment: 01/01/2021
Medical Facilities Type: Hospitalization
Period of Medical Facilities: 01/01/2020 to 01/01/2021
Date of Payment: 01/01/2021
Other Benefits Type: Maternity Leave
Period of Benefits: 01/01/2020 to 01/01/2021
Date of Payment: 01/01/2021
Other Deductions Type: Tax Deductions
Period of Deductions: 01/01/2020 to 01/01/2021
Date of Payment: 01/01/2021
Other Contributions Type: Pension Contributions
Period of Contributions: 01/01/2020 to 01/01/2021
Date of Payment: 01/01/2021
Other Expenses Type: Travel Expenses
Period of Expenses: 01/01/2020 to 01/01/2021
Date of Payment: 01/01/2021
Other Documents Type: Medical Records
Period of Documents: 01/01/2020 to 01/01/2021
Date of Submission: 01/01/2021
Employer Signature: ___________________
Date of Submission: 01/01/2021
Conclusion
ESIC Form 10 is an important document for employers and employees who are covered under the Employees’ State Insurance Corporation (ESIC). It is important to fill the form accurately and submit it on time to ensure that the employees are able to avail the benefits of the scheme. The steps to fill the form are mentioned above and a sample filled form is also provided for reference.
