FORM-01(A)

FORM OF ANNUAL INFORMATION ON FACTORY/ESTABLISHMENT

COVER UNDER ESI ACT
(Regulation 10C)
Employers Code No. ____________________________
1.

Name of the Factory/Establishment

2.

Complete
Postal
Factory/Establishment

Address

of

the

Pin
3.

4.

a)

Telephone No., if any

b)

Fax No., if any

c)

E-mail address, if any

Location of Factory/Establishment

a) State
b) District
c) Municipality/Ward
d) Name of Town/Revenue Village
(Taluk/Tehsil)
e) Police Station
f) Revenue Demarcation/Hudbast No.
5.

6.

Details of Bank Account

Name of Bank and Branch

a) Account No. .

b) Account No. .

c) Account No. .

a) Income Tax PAN/GIR No.

b) Income Tax Ward/Circle/Area

7.

a) In case of factory whether Licence issued Under

Section 2(m) (i) or 2(m) (ii) of the Factories Act,
1948
b) Power Connection No.

8.

No.
Sanctioned Power Load
Issuing Authority
a) Whether it is Public or Private Ltd., Company/
Partnership/Proprietorship/Cooperative
Society/
Ownership
(attach
copy
of
Memorandum
and
Articles
of
Association/Partnership Deed/ Resolution
b) Give name, present and permanent residential
address of present Proprietor/Managing Directors,
Director/ Managing Partners, Partners/Secretary of
the Cooperative Society.

i)

Name

Designati
on

Address

ii)
iii
)
iv
)
v)
vi
)
vii
)

9.

Address(es)
of
the
Registered
Office/Head
Office/Branch Office/Sales Office/Administrative
Office/other offices if any, with no. of employees
attached with each such office and person
responsible for the office.
Address as on Date
No. of Employee
Phone No./Fax No.
Work
Person responsible for day to day functioning of
the office
(Give details on a separate sheet, if required.)

10
.

a)
b)

Whether any work/business carried out

through contractor/immediate employer.
If yes, give nature of such work/business

I hereby declare that the statement given above is correct to the best of my
knowledge and belief. I also undertake to intimate changes, if any, promptly to the
Regional Office/Sub Regional Office, ESI Corporation as soon as such changes take
place.
Date

Name & Signature

Place ..

Designation with seal ..

(Should be signed by principal employer u/s 2(17) of ESI Act

FORM-01(A)

FORM OF ANNUAL INFORMATION ON FACTORY/ESTABLISHMENT

COVER UNDER ESI ACT
(Regulation 10C)
Employers Code No. ____________________________
1.

Name of the Factory/Establishment

2.

Complete
Postal
Factory/Establishment

Address

of

the

Pin
3.

4.

a)

Telephone No., if any

b)

Fax No., if any

c)

E-mail address, if any

Location of Factory/Establishment

a) State
b) District
c) Municipality/Ward
d) Name of Town/Revenue Village
(Taluk/Tehsil)
e) Police Station
f) Revenue Demarcation/Hudbast No.
5.

6.

Details of Bank Account

Name of Bank and Branch

a) Account No. .

b) Account No. .

c) Account No. .

a) Income Tax PAN/GIR No.

b) Income Tax Ward/Circle/Area

7.

a) In case of factory whether Licence issued Under

Section 2(m) (i) or 2(m) (ii) of the Factories Act,
1948
b) Power Connection No.

8.

No.
Sanctioned Power Load
Issuing Authority
a) Whether it is Public or Private Ltd., Company/
Partnership/Proprietorship/Cooperative
Society/
Ownership
(attach
copy
of
Memorandum
and
Articles
of
Association/Partnership Deed/ Resolution
b) Give name, present and permanent residential
address of present Proprietor/Managing Directors,
Director/ Managing Partners, Partners/Secretary of
the Cooperative Society.

i)

Name

Designati
on

Address

ii)
iii
)
iv
)
v)
vi
)
vii
)

9.

Address(es)
of
the
Registered
Office/Head
Office/Branch Office/Sales Office/Administrative
Office/other offices if any, with no. of employees
attached with each such office and person
responsible for the office.
Address as on Date
No. of Employee
Phone No./Fax No.
Work
Person responsible for day to day functioning of
the office
(Give details on a separate sheet, if required.)

10
.

a)
b)

Whether any work/business carried out

through contractor/immediate employer.
If yes, give nature of such work/business

I hereby declare that the statement given above is correct to the best of my
knowledge and belief. I also undertake to intimate changes, if any, promptly to the
Regional Office/Sub Regional Office, ESI Corporation as soon as such changes take
place.

Date

Name & Signature

Place ..

Designation with seal ..

(Should be signed by principal employer u/s 2(17) of ESI Act

FORM-01(A)

FORM OF ANNUAL INFORMATION ON FACTORY/ESTABLISHMENT

COVER UNDER ESI ACT
(Regulation 10C)
Employers Code No. ____________________________
1.

Name of the Factory/Establishment

2.

Complete
Postal
Factory/Establishment

Address

of

the

Pin
3.

4.

a)

Telephone No., if any

b)

Fax No., if any

c)

E-mail address, if any

Location of Factory/Establishment

a) State
b) District
c) Municipality/Ward
d) Name of Town/Revenue Village
(Taluk/Tehsil)
e) Police Station
f) Revenue Demarcation/Hudbast No.
5.

Details of Bank Account

Name of Bank and Branch

a) Account No. .

b) Account No. .

c) Account No. .

6.

a) Income Tax PAN/GIR No.

b) Income Tax Ward/Circle/Area

7.

a) In case of factory whether Licence issued Under

Section 2(m) (i) or 2(m) (ii) of the Factories Act,
1948
b) Power Connection No.

8.

No.
Sanctioned Power Load
Issuing Authority
a) Whether it is Public or Private Ltd., Company/
Partnership/Proprietorship/Cooperative
Society/
Ownership
(attach
copy
of
Memorandum
and
Articles
of
Association/Partnership Deed/ Resolution
b) Give name, present and permanent residential
address of present Proprietor/Managing Directors,
Director/ Managing Partners, Partners/Secretary of
the Cooperative Society.

i)

Name

Designati
on

Address

ii)
iii
)
iv
)
v)
vi
)
vii
)

9.

Address(es)
of
the
Registered
Office/Head
Office/Branch Office/Sales Office/Administrative
Office/other offices if any, with no. of employees
attached with each such office and person
responsible for the office.
Address as on Date
No. of Employee
Phone No./Fax No.
Work
Person responsible for day to day functioning of
the office
(Give details on a separate sheet, if required.)

10
.

a)
b)

Whether any work/business carried out

through contractor/immediate employer.
If yes, give nature of such work/business

I hereby declare that the statement given above is correct to the best of my
knowledge and belief. I also undertake to intimate changes, if any, promptly to the

Regional Office/Sub Regional Office, ESI Corporation as soon as such changes take
place.
Date

Name & Signature

Place ..

Designation with seal ..

(Should be signed by principal employer u/s 2(17) of ESI Act

FORM-01(A)

FORM OF ANNUAL INFORMATION ON FACTORY/ESTABLISHMENT

COVER UNDER ESI ACT
(Regulation 10C)
Employers Code No. ____________________________
1.

Name of the Factory/Establishment

2.

Complete
Postal
Factory/Establishment

Address

of

the

Pin
3.

4.

a)

Telephone No., if any

b)

Fax No., if any

c)

E-mail address, if any

Location of Factory/Establishment

a) State
b) District
c) Municipality/Ward
d) Name of Town/Revenue Village
(Taluk/Tehsil)
e) Police Station
f) Revenue Demarcation/Hudbast No.
5.

Details of Bank Account

Name of Bank and Branch

a) Account No. .

b) Account No. .

c) Account No. .

6.

a) Income Tax PAN/GIR No.

b) Income Tax Ward/Circle/Area

7.

a) In case of factory whether Licence issued Under

Section 2(m) (i) or 2(m) (ii) of the Factories Act,
1948
b) Power Connection No.

8.

No.
Sanctioned Power Load
Issuing Authority
a) Whether it is Public or Private Ltd., Company/
Partnership/Proprietorship/Cooperative
Society/
Ownership
(attach
copy
of
Memorandum
and
Articles
of
Association/Partnership Deed/ Resolution
b) Give name, present and permanent residential
address of present Proprietor/Managing Directors,
Director/ Managing Partners, Partners/Secretary of
the Cooperative Society.

i)

Name

Designati
on

Address

ii)
iii
)
iv
)
v)
vi
)
vii
)

9.

Address(es)
of
the
Registered
Office/Head
Office/Branch Office/Sales Office/Administrative
Office/other offices if any, with no. of employees
attached with each such office and person
responsible for the office.
Address as on Date
No. of Employee
Phone No./Fax No.
Work
Person responsible for day to day functioning of
the office
(Give details on a separate sheet, if required.)

10
.

a)
b)

Whether any work/business carried out

through contractor/immediate employer.
If yes, give nature of such work/business

I hereby declare that the statement given above is correct to the best of my
knowledge and belief. I also undertake to intimate changes, if any, promptly to the
Regional Office/Sub Regional Office, ESI Corporation as soon as such changes take
place.
Date

Name & Signature

Place ..

Designation with seal ..

(Should be signed by principal employer u/s 2(17) of ESI Act

FORM-01(A)

FORM OF ANNUAL INFORMATION ON FACTORY/ESTABLISHMENT

COVER UNDER ESI ACT
(Regulation 10C)
Employers Code No. ____________________________
1.

Name of the Factory/Establishment

2.

Complete
Postal
Factory/Establishment

Address

of

the

Pin
3.

4.

a)

Telephone No., if any

b)

Fax No., if any

c)

E-mail address, if any

Location of Factory/Establishment

a) State
b) District
c) Municipality/Ward
d) Name of Town/Revenue Village
(Taluk/Tehsil)
e) Police Station
f) Revenue Demarcation/Hudbast No.
5.

Details of Bank Account

Name of Bank and Branch

a) Account No. .

b) Account No. .

c) Account No. .

6.

a) Income Tax PAN/GIR No.

b) Income Tax Ward/Circle/Area

7.

a) In case of factory whether Licence issued Under

Section 2(m) (i) or 2(m) (ii) of the Factories Act,
1948
b) Power Connection No.

8.

No.
Sanctioned Power Load
Issuing Authority
a) Whether it is Public or Private Ltd., Company/
Partnership/Proprietorship/Cooperative
Society/
Ownership
(attach
copy
of
Memorandum
and
Articles
of
Association/Partnership Deed/ Resolution
b) Give name, present and permanent residential
address of present Proprietor/Managing Directors,
Director/ Managing Partners, Partners/Secretary of
the Cooperative Society.

i)

Name

Designati
on

Address

ii)
iii
)
iv
)
v)
vi
)
vii
)

9.

Address(es)
of
the
Registered
Office/Head
Office/Branch Office/Sales Office/Administrative
Office/other offices if any, with no. of employees
attached with each such office and person
responsible for the office.
Address as on Date
No. of Employee
Phone No./Fax No.
Work
Person responsible for day to day functioning of
the office
(Give details on a separate sheet, if required.)

10
.

a)
b)

Whether any work/business carried out

through contractor/immediate employer.
If yes, give nature of such work/business

I hereby declare that the statement given above is correct to the best of my
knowledge and belief. I also undertake to intimate changes, if any, promptly to the
Regional Office/Sub Regional Office, ESI Corporation as soon as such changes take
place.
Date

Name & Signature

Place ..

Designation with seal ..

(Should be signed by principal employer u/s 2(17) of ESI Act

FORM-01(A)

FORM OF ANNUAL INFORMATION ON FACTORY/ESTABLISHMENT

COVER UNDER ESI ACT
(Regulation 10C)
Employers Code No. ____________________________
1.

Name of the Factory/Establishment

2.

Complete
Postal
Factory/Establishment

Address

of

the

Pin
3.

4.

a)

Telephone No., if any

b)

Fax No., if any

c)

E-mail address, if any

Location of Factory/Establishment

a) State
b) District
c) Municipality/Ward
d) Name of Town/Revenue Village
(Taluk/Tehsil)
e) Police Station
f) Revenue Demarcation/Hudbast No.
5.

Details of Bank Account

Name of Bank and Branch

a) Account No. .

6.

b) Account No. .

c) Account No. .

a) Income Tax PAN/GIR No.

b) Income Tax Ward/Circle/Area

7.

a) In case of factory whether Licence issued Under

Section 2(m) (i) or 2(m) (ii) of the Factories Act,
1948
b) Power Connection No.

8.

No.
Sanctioned Power Load
Issuing Authority
a) Whether it is Public or Private Ltd., Company/
Partnership/Proprietorship/Cooperative
Society/
Ownership
(attach
copy
of
Memorandum
and
Articles
of
Association/Partnership Deed/ Resolution
b) Give name, present and permanent residential
address of present Proprietor/Managing Directors,
Director/ Managing Partners, Partners/Secretary of
the Cooperative Society.

i)

Name

Designati
on

Address

ii)
iii
)
iv
)
v)
vi
)
vii
)

9.

Address(es)
of
the
Registered
Office/Head
Office/Branch Office/Sales Office/Administrative
Office/other offices if any, with no. of employees
attached with each such office and person
responsible for the office.
Address as on Date
No. of Employee
Phone No./Fax No.
Work
Person responsible for day to day functioning of
the office
(Give details on a separate sheet, if required.)

10
.

a)

Whether any work/business carried out

through contractor/immediate employer.

b)

If yes, give nature of such work/business

I hereby declare that the statement given above is correct to the best of my
knowledge and belief. I also undertake to intimate changes, if any, promptly to the
Regional Office/Sub Regional Office, ESI Corporation as soon as such changes take
place.
Date

Name & Signature

Place ..

Designation with seal ..

(Should be signed by principal employer u/s 2(17) of ESI Act

Forms

Form01
Form01(A)
Form1
Form1A
Form1B
Form3
Form4
Form4(A)
Form5
Form7
Form8

Employers' Registration Form

Form10

Abstention verification in r/o Sickness Benefit/Temporary Disablement

Benefit/MB

Form12
Form12A
Form13
Form13A
Form14
Form14A
Form16
Form17
Form18
Form18A
Form19
Form20
Form21
Form22
Form23
Form24
Form25
Form26

(Word Format) (PDF Format)

Form of Annual Information on Factory/Establishment (Word Format)

Declaration Form (Word Format) (PDF Format)

Family Declaration Form
Changes in Family Declaration Form
Return of Declaration Forms
Identity Card
Family Identity Card
Return of Contributions
FIRST/INTERMEDIATE/FINAL CERTIFICATE
SPECIAL INTERMEDIATE CERTIFICATE
Sickness of Temporary Disablement Benefit
Maternity Benefit for Sickness
Sickness or Temporary disablement or maternity benefit for sickness
Maternity benefit for sickness
Sickness or temporary disablement or maternity benefit for sickness
Maternity Benefit for Sickness
Accident report from employer
Dependant's or funeral benefit (Death Certificate)
Dependant's Benefit (Claim Form)
Dependant's Benefit ( Claim for periodical payments)
Maternity Benefit ( Notice of Pregnancy)
Maternity Benefit ( Certificate of Pregnancy)
Maternity Benefit (Cetificate of expected confinement)
Claim for Maternity Benefit
Maternity Benefit (Certificate of confinement or miscarriage)
Maternity Benefit (Notice of work)
Claim for Permanent Disablement Benefit
Certificate for permanent disablement benefit

Form27

Declaration and certificate for depenant's benefit