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.__________________
