FORM 28:
[Regulation 52A]
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. He/she has further declared that he / she has not received wages for any leave holiday/weekly off/lay-off and was not on strike for the above period of incapacity.
I shall be grateful for your confirmation on the Form appended within ten days of the receipt of the said Form.
Your faithfully
Manager
REPLY TO BE FURNISHED BY THE EMPLOYER IN RESPECT OF FORM NO. 23 QUERY
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 ______________
It is further confirmed that-
(a) He/she had remained on leave with wages for the period from _________ to ________
(b) He/she had remained on holidays with wages from ____ to _____________
(c) He/she was weekly off with wages for ______________
(d) He/she was on lay-off with wages from ________ to ____________
(e) He/she was on strike from _________ to _____________________
If the IP is paid any wages for any of the days during the above period subsequently, the same will be notified to you in due course.
The day preceding the first day of absence was / was not a holiday for insured person.
_______________
Signature
Name and Designation __________________
Code No __________
