Form 28a – EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS,1950

FORM 28A

[Regulation52A]

From

    The Manager

    ___________ (address of local office)

    ESI Corporation

To

    M/s_________

    Name of the insured person _________

    Insurance No _____________________

    Department _____________________

Dear Sir(s)

    The above named employee of your factory has submitted a certificate of incapacity for the period from _____ to _______  and has declared that he/ she has not worked on any day during this period.

    I shall be grateful for your confirmation on the Form appended, within ten days of the receipt of aforesaid Form.

Yours faithfully,

Manager

REPLY TO BE FURNISHED BY THE EMPLOYER

Name of the insured person __________

Insurance No _____________________

    Returned with the remarks that the employee in question has not worked on any day during the period from _________ to __________ except on the following day/ days.

    The day preceding the first day of absence was/was not a holiday for the insured person.

Signature ____________

Name and designation __________

Code no.__________________

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