EMPLOYEE STATE INSURANCE (GENERAL) REGULATIONS

Certification and Claims For Sickness

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Rule 63 : Form of claim for sickness or temporary disablement

An insured person intending to claim sickness benefit or disablement benefit for temporary disablement shall submit to the appropriate Branch Office by post or otherwise, a claim for benefit in Form 9, appropriate to the circumstances of the case together with the appropriate medical certificate:

Provided that where only one claim in Form 9 is submitted in respect of more than one certificates, such Form 9 shall be deemed to be appropriate to all such certificates.
Form 12 — Regulation 68 : Accident Report From Employer (Old Form 16) Form 13 — Regulation 79 and 95-C : Death Certificate (Old Form 17) Form 14 — Regulation 76-A : Claim for Permanent Disablement Benefit (Old Form 25)