**Executive Summary:**
This document pertains to amendments to the Employees' State Insurance General Regulations, 1950, as per the Employees' State Insurance Act, 1948. It introduces regulations concerning maternity benefits for commissioning mothers and adoptive mothers, and revises related forms. The regulations come into force upon publication in the Gazette of India.
**Key Points / Main Content:**
* **Amendments to Employees' State Insurance General Regulations, 1950:**
* Regulations are amended under Section 97 of the Employees' State Insurance Act, 1948.
* **Maternity Benefits for Commissioning Mothers:**
* **Regulation 87 A:** An insured woman seeking embryo implantation in another woman must notify the branch office using amended Form 17, along with the embryo implantation agreement.
* **Regulation 89 C:** A commissioning mother claiming maternity benefit must submit amended Form 19, a copy of the agreement with the other woman (on non-judicial stamp paper), a certificate from the Assisted Reproductive Technology Clinic, and a copy of the birth certificate.
* If both women are insured, the commissioning mother receives the benefit.
* Miscarriage claims are not payable to either woman.
* **Maternity Benefits for Adoptive Mothers:**
* **Regulation 89 D:** An insured woman who legally adopts a child (up to 3 months old) must submit amended Form 19, a copy of the court order/certificate from Registrar and birth certificate.
* If the adoption is annulled, the insured woman must refund the maternity benefit.
* **General Maternity Benefit Rules:**
* Giving birth to twins is treated as a single claim.
* False statements to obtain benefits are punishable with imprisonment or a fine, or both.
* No work for remuneration is allowed during the claim period.
* **Revised Forms:**
* Form 17 (Notice of Pregnancy/Maternity Benefit) and Form 19 (Claim for Maternity Benefit and Notice of Work) are revised.
* **Effective Date:**
* The regulations take effect upon publication in the Gazette of India.
**Impact Analysis:**
**Employees' State Insurance Corporation:**
* *Impact:* Required to implement and administer the new regulations regarding maternity benefits for commissioning and adoptive mothers, as well as the revised forms.
* *Action Required:* Update internal processes, train staff on the new regulations, and ensure the revised forms are available and correctly processed.
**Insured Women (Commissioning Mothers):**
* *Impact:* Entitled to claim maternity benefits under specific conditions, including providing necessary documentation.
* *Action Required:* Understand the new regulations, complete the required forms (Form 17 and Form 19), and submit all necessary documents, including the embryo implantation agreement, ART clinic certificate, and birth certificate.
**Insured Women (Adoptive Mothers):**
* *Impact:* Entitled to claim maternity benefits upon legally adopting a child, subject to providing required documentation.
* *Action Required:* Understand the new regulations, complete the required form (Form 19), and submit all necessary documents, including the court order/certificate from Registrar, birth certificate, and adoption order.
**Insured Women (General):**
* *Impact:* Subject to updated rules and guidelines for maternity benefits, including providing accurate information and adhering to work restrictions during the claim period.
* *Action Required:* Familiarize themselves with the updated regulations and ensure compliance with all requirements when claiming maternity benefits.
Key Entities Referenced
Employees State Insurance Act, 1948: A law concerning employee state insurance, referenced as the basis for regulations and amendments.
Employees State Insurance General Regulations, 1950: Regulations under the Employees State Insurance Act, 1948, that are being amended by this notification.
Employees' State Insurance Corporation: The organization responsible for making the regulations and amendments to the Employees State Insurance General Regulations.
Registration of Births Deaths Act, 1969: An act related to the registration of births and deaths, relevant to the documentation required for claiming maternity benefits for adoptive mothers and commissioning mothers.
Form 17: A form related to the notice of pregnancy and maternity benefits, mentioned in the context of commissioning mothers.
Form 19: A form related to the claim for maternity benefits and notice of work, applicable to commissioning and adopting mothers.
New Delhi: The location where the notification was issued.
Indian Council of Medical Research: An organization that recognizes Assisted Reproductive Technology Clinics, relevant to the certification required for commissioning mothers.
रजिस्ट्री स.ं डी.एल.- 33004/99 REGD. No. D. L.-33004/99
सी.जी.-डी.एल.-अ.-18052020-219426
xxxGIDHxxx
CG-DL-E-18052020-219426
xxxGIDExxx
असाधारण
EXTRAORDINARY
भाग III—खण् ड 4
PART III—Section 4
प्राजधकार स ेप्रकाजित
PUBLISHED BY AUTHORITY
स.ं 175] िई दिल्ली, सोर्वार, र्ई 18, 2020/विै ाख 28, 1942
No. 175] NEW DELHI, MONDAY, MAY 18, 2020/VAISAKHA 28, 1942
कर्चम ारी राज्य बीर्ा जिगर्
अजधसचू िा
िई दिल् ली, 20 र्ाचम, 2020
स.ंएि.-12/13/1/2016-यो.एव ं जव. —िबदक कर्मचारी राज्य बीर्ा (साधारण) जवजियर्, 1950 र् ें और
संिोधि करिे के कजतपय र्सौिा जवजियर् कर्मचारी राज्य बीर्ा अजधजियर्, 1948 (1948 का 34) की धारा 97
की उप-धारा (1) के अंतगमत यथा अपेजित भारत के रािपत्र, (असाधारण), भाग-III, खण् ड-4 र् ें स.ं 52, दििांक 24
ििवरी, 2020 जििर् ें उक्त अजधसूचिा प्रकाजित की गई थी, ििता को उपलब् ध करािे की तारीख स े तीस दिि की
अवजध की सर्ाजि तक, इससे प्रभाजवत होिे वाले सभी व् यजययं स,े आपजियॉं और सुझाव आर्ंजत्रत दकय े गय ेथ े।
िबदक उक्त रािपत्र की प्रजतयां दििांक 11.02.2020 स े सावमिजिक उपयोग के जलए ििता को उपलब् ध
करा िी गयी थी; और प्रभाजवत होिे वाल े सम्भाजवत व्यजययं स े कोई भी आपजियां या सुझाव प्राि िहीं हुए;
अत: अब कर्मचारी राज्य बीर्ा जिगर्, कर्मचारी राज्य बीर्ा अजधजियर्, 1948 (1948 का 34) की धारा
97 द्वारा प्रित् त िजययं का प्रयोग करते हुए, कर्मचारी राज्य बीर्ा (साधारण) जवजियर्, 1950 र् ें पुि: संिोधि
करिे हते ु जिम्ि जलजखत जवजियर् बिाती ह;ै अथामत ् : —
जवजियर्ावली
1. ये जवजियर् कर्मचारी राज्य बीर्ा (सार्ान् य) (प्रथर्) संिोजध त जवजियर्, 2020 कह े िाएंगे।
2. कर्मचारी राज्य बीर्ा (सार्ान् य), 1950 र् ें जवजियर्ं तथा जवजियर् प्रपत्रं र् ेंजिम्ि जलजखत पररवतमि दकए
2077 GI/2020 (1)2 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III—SEC. IV]
िाएंगे।
i. जवजियर् 87क का अतं विे ि : कर्ीिनिगं र्ाता की सचू िा
कोई बीर्ाकृत र्जहला िो संताि चाहती ह ै और दकसी अन् य र्जहला र् ें भ्रूण प्रत् यारोपण करवाती ह ै तो वह
उपयुक् त िाखा कायामलय को डाक के र्ाध् यर् स े अथवा अन् यथा संिोजधत फॉर् म 17 र् ें इसकी सूचिा िगे ी
तथा कजर्िनिगं र्ाता और अन्य र्जहला के र्ध् य हुए भ्रूण प्रत् यारोपण के करार के साथ इस े प्रस्ट्त ुत करेगी।
ii. जवजियर् 88क का अतं विे ि : बीर्ाकृत र्जहला द्वारा अपिा िीजवत बच्च ा अथवा बच्च ं की घोषणा
प्रसूजत पूव म अथवा प्रसूजत या गभमपात पश् चात ् र्ातृत्व जहतलाभ का िावा करि े वाली बीर्ाकृत र्जहला अपि े
िीजवत बच् चे अथवा बच् चं की घोषणा प्रस्ट्त ुत करेगी। ‘‘बीर्ाकृत र्जहला द्वारा एक स े अजधक बच् चं को
िन् र् ििे े की जस्ट्थजत र् ें यह िावा, एकल िावा र्ािा िाएगा, तथाजप, अगली प्रसूजत के जलए र्ातृत्व
जहतलाभ का िावा करत े सर्य िीजवत बच् चं की वास्ट् तजवक सख्ं या के अिुसार िीजवत बच् चं की संख् या की
गणिा की िाएगी।’’
iii. 89ग का अतं विे ि : कर्ीिनिगं र्ाता द्वारा र्ातत्ृ व जहतलाभ का िावा
जवजियर् 89 ग : प्रत् येक कजर्िनिंग र्ाता िो, िैजवक र्ाता के रूप र् ें अपिी संताि चाहती ह ै और दकसी
अन् य र्जहला र् ें भ्रूण प्रत् यारोपण करािा चा हती ह ै तथा र्ातृत्व जहतलाभ का िावा प्रस्ट् तुत करती ह ै तो वह
डाक के र्ाध् यर् स े अथवा अन् यथा उपयुक्त कायामलय को र्ातृत्व जहतलाभ के िावे हते ु प्रपत्र-19 (संिोजधत),
न् याजयकेतर स्ट् ांप पेपर र् ें कजर्िनिंग र्ाता और अन् य र्जहला िो भ्रूण प्रत् यारोपण हते ु अजभप्रेत ह,ै के बीच
हुए करार की प्रजत, सहायक प्रििि प्रौद्योजगकी जक्लजिक द्वारा िारी प्रर्ाणपत्र की प्रजत और िन् र् और
र्ृत् य ु रजिस्ट् रीकरण अजधजियर्, 1969 के कायामलय के प्राजधकारी द्वारा िारी िन् र् प्रर्ाणपत्र की प्रजत के
साथ प्रस्ट् ततु करेगी।
आग े ित म यह ह ै दक यदि कजर्िनिंग र्ाता और अन् य र्जहला िोिं बीर्ाकृत र्जहलाए ं ह,ैं तब केवल
कजर्िनिंग र्ाता को िावा दिया िाएगा। गभमपात के जलए कजर्िनिंग र्ाता और अन् य र्जहला को भी िावा
िये िहीं होगा।
iv. ििकी र्ाता द्वारा र्ातत्ृ व जहतलाभ हते ु89घ िावा का अतं विे ि
जवजियर् 89 (घ) : प्रत् यके बीर्ाकृत र्जहला िो 3 र्ाह की उम्र तक के बच् च े को काििू ी तौर पर गोि लेती
ह,ै र्ातृत्व जहतलाभ का िावा प्रस्ट् तुत करती ह ै तो वह डाक के र्ाध् यर् स े अथवा अन् यथा उपयुक् त कायामलय
को र्ातृत्व जहतलाभ के िाव े (प्रपत्र-19 संिोजधत) के साथ गोि लेि े वाले र्ाता-जपता अथवा कािूिी रूप स े
गोि लेिे वाली एकाकी बीर्ाकृत र्जहला का िार् िाजर्ल करते हुए न् यायालय आििे /रजिस्ट् रार स े
प्रर्ाणपत्र तथा िन् र् और र्ृत् य ु रजिस्ट् रीकरण अजधजियर्, 1969 के अंतगमत प्राजधकारी द्वारा िारी िन् र्
प्रर्ाणपत्र की प्रजत तथा सिर् न् यायालय द्वारा िारी गोि लेि े के आिेि की प्रजत के साथ िावा प्रस्ट् तुत
करेगी।
न् यायालय द्वारा अिुर्ोदित ित् तक ग्रहण जिरसि की जस्ट्थजत र् ें बीर्ाकृत र्जहला, प्राप् त र्ातृत्व जहतलाभ को
वापस करेगी।
v. दििाकं 23 अक् ूबर, 2004 को भारत का रािपत्र (भाग-IV, धारा-4) र् ेंप्रकाजित सख्ं य ा एि-
11/13/2/2003-यो.एव ं जव., दििाकं 01.10.2004 द्वारा यथाअजधसूजचत जवजियर् सिं ोजधत प्रपत्र सख्ं य ा
17 तथा प्रपत्र सख्ं य ा 19 र्सौिा जवजियर्ं की इस अजधसचू िा के साथ यथा सलं ग्ि को सिं ोजधत प्रपत्रं स े
प्रजतस्ट्थ ाजपत दकया िाएगा।
3. ये भारत का रािपत्र र् ेंअंजतर् अजधसूचिा के प्रकािि के पश् चात प्रवृि हंगे।
[जवज्ञापि-III/4/असा./31/2020-21]
ए.के.जसन् हा, बीर्ा आयुक् त[भाग III—खण् ड 4] भारत का रािपत्र : असाधारण 3
प्रपत्र 17
प्रर्ाणपत्र/गभावम स्ट्थ ा की िोरस
(बीर्ाकृत र्जहला/कर्ीिनिगं र्ाता का िोरस)
र्ा तत्ृ व जहतलाभ
(जवजियर् 87 और 87क)
कर्चम ारी राज्य बीर्ा जिगर्
बीर्ाकृत र्जहला के हस्ट्त ािर
अथवा अंगूठे का जििाि
बुक स.ं ...................................
क्र.स.ं ......................................
जियोक्त ा कू स.ं ................................................
बीर्ाकृत र्जहला का िार् .....................................
बीर्ा संख् या ........................................................
औषधालय की र्हु र
प्रर्ाजणत दकया िाता ह ैदक र्ैंि े उपुयमक् त बीर्ाकृत र्जहला की िांच की ह ैऔर र्ेरे जवचार स ेवह गभमवती ह ैं
तथा उिकी गभामवस्ट् था ................................. सप् ताह की प्रतीत होती ह।ै
या {सर्ाजवष् करिे हते ु प्रस्ट् ताजवत}
प्रर्ाजणत दकया िाता ह ै दक र्िैं े कर्ीिनिगं र्ाता के साथ अन्य र्जहला के बीच जिष्प ादित भ्रणू प्रत्य ारोपण
के र्लू करार की िाचं की ह।ै र्िैं े भारतीय जचदकत्स ा अिसु धं ाि पररषि द्वारा र्ान्य ता प्राप्त एजसस्ट् ेड ररप्रोडजक्व
ेक्ि ोलॉिी जक्लनिगं द्वारा िारी दकए गए भ्रणू प्रत्य ारोपण के प्रर्ाणपत्र की भी िाचं की ह।ै
दििाकं ...........................................
.............................................................
बीर्ाकृत जचदकत्स ा अजधकारी के हस्ट्त ािर
या प्रजत हस्ट्त ािर
.............................................................
बडे अिरं र् ेंिार् और रबड़ र्हु र
कोई अन्य अभ्य जु य ........................................................
र्,ैं …………………………………………………………………………. बीर्ा सख्ं य ा
.................................................... पत्ि ी/पत्रु ी ...................................................... एतद्द्वारा अपि े
गभावम स्ट्थ ा का िोरस िेती ह।ूँ
र्,ैं …………………………………………………………………………. बीर्ा सख्ं य ा
.................................................... पत्ि ी/पत्रु ी ...................................................... कर्ीिनिगं के जलए
करार की प्रजत एतद्द्वारा प्रस्ट्त तु करती ह।ूँ
वतर्म ाि पता4 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III—SEC. IV]
..............................................................................................................................................
वतर्म ाि/जपछला जियोक्त ा
.............................................................................................................................
दििाकं ...............................................................
......................................................................
बीर्ाकृत र्जहला के हस्ट्त ािर या अगं ठू े का जििाि
प्रपत्र 19
प्रसजू त जहतलाभ के जलए िावा और काय म का िोरस
[वतमर्ाि जवजियर् {88(ii), 89 और जवजियर् 91},
िया िोड़ा गया जवजियर् {{88(iv), 89(ग) तथा 89(घ) }
कर्मचारी राज्य बीर्ा जिगर्
बीर्ाकृत र्जहला के हस्ट्त ािर
अथवा अंगूठे का जििाि
बुक स.ं ...................................
क्र.स.ं ......................................
जियोक्त ा कू स.ं ................................................
बीर्ाकृत र्जहला का िार् .....................................
बीर्ा संख् या ........................................................
पत् िी/बेी का ......................................................
औषधालय की र्ुहर
र्ैं, उपयुमक् त बीर्ाकृत र्जहला एतद्द्वारा ............................................. से संभाजवत प्रसूजत या प्रसूजत अथवा स्ट् वयं या
कर्ीिनिंग र्ाता या गोि लेिे वाली र्ात ाा के गभमपात के जलए प्रसूजत जहतलाभा का िावा करती हं।
र्ैं, इसके अजतररक् त घोषणा करती ह ंदक र्ैंिे उपयुमक् त जतथ जा ............................................. से पाररश्रजर् क के जलए कायम
करिा बंि कर दिया ह/ैबंि कर िगंू ी।
*र्ैं एतद्द्वारा िोरस िते ी ह ंदक र्ैंि ेदििांक .................................. से पाररश्रजर्क के जलए कायमग्रहण कर जलया ह/ैकरूंगी। र्ैंिे
र्ातृत् व जहतलाभ केवल दििांक .................................... तक प्राप् त दकया ह।ै
***र्ैं एतद्द्वारा घोषणा करती ह ंदक इस जतजथ को र्ेरी जिम् िािुसार संताि ह/ैह ैंऔर एतद्द्वारा घोषणा करती ह ंदक प्रस्ट् तुत की गई
सूचिा सही तथा कुछ भी जछपाया िहीं गया ह।ै
क्र.सं. बीर्ाकृत र्जहला का िार् नलंग िन् र्जतजथ
पहली संताि
िसू री संताि
तीसरी संताि
चौथी संताि
वतमर्ाि/जपछला जियोक् ता** ............................................
जवभाग, पाली तथा व् यवसाय .........................................
वतमर्ाि पता ................................................................
बीर्ाकृत र्जहला के हस्ट् तािर अथवा अंगूठे का जििाि
दििांक ........................................... िाखा का िार्[भाग III—खण् ड 4] भारत का रािपत्र : असाधारण 5
कायामलय .........................................
* कृपया िो भी लागू ि हो उसे हा ि ें
** यदि रोिगार र्ें िहीं है, जपछले जियोक् ता का जववरण िें।
*** उपयुमक् त घोषणा कर्ीिनिंग र्ाता और गोि लेिे वाली र्ाता पर लागू िहीं ह।ै
आवश्य क :
1. अवजध जिसके जलए र्ातृत् व जहतलाभा का िावा दकया िाता ह ै अथवा िावा दकया िािा है, के िौराि पाररश्रजर् क के
जलए कोई कायम िहीं दकया िाएगा।
2. कोई भी कायम िुरू करिे से पहले कायम पुि: आरंभ करिे की सूचिा भेििी होगी।
3. यदि कर्ीिनिंग र्ाता एव ं अन् य र्जहला िोिं बीर्ाकृत र्जहला है, तब िाव े का भुगताि केवल कर्ीिनिंग र्ाता को
दकया िाएगा।
गभमपात की जस्ट्थजत र्ें कर्ीिनिंग र्ाता के साथ-साथ अन् य र्जहला को भी िावा भुगताि िये िहीं होगा।
4. यदि न्यायालय द्वारा गोि लेिे को अर्ान् य ठहराया िाता ह ै तो बीर्ाकृत र्जहला, उसे भुगताि की गई र्ातृत् व
जहतलाभ की पूरी राजि वापस करेगी।
5. यदि बीर्ाकृत र्जहला िुड़वा बच् चं को िन् र् िते ी है, तो ऐसा िावा एकल िावा र्ािा िाएगा।
6. दकसी व् यजय द्वारा स्ट् वयं के जलए या दकसी अन् य व् यजय के जलए जहतलाभ प्राप्त करिे के उद्देश् य से झूठा बयाि अथवा
अभ् यावेिि िडं िीय अपराध ह ै जिसके जलए वह छह र्ाह तक कारावास या रु. 2000/- का िुर्ामिा या िोिं से ही
िजं डत करिे योग्य होगा।
EMPLOYEES' STATE INSURANCE CORPORATION
NOTIFICATION
New Delhi, the 20th March, 2020
No. N-12/13/1/2016-P&D:—Whereas draft Regulation further to amend the Employees’ State
Insurance (General) Regulations, 1950 was published as required under sub-section (1) of Section 97
of the Employees’ State Insurance Act, 1948 (34 of 1948), in the Gazette of India (Extraordinary),
Part-III – Section – 4 vide Sr. No.52 dated the 24th January, 2020 for inviting objections and
suggestions from all persons likely to be affected thereby till the expiry of the period of Thirty days
from the date on which this notification was published, are made available to the public :—
And whereas, the said Gazette Notification were made available to the public on 11.02.2020;
And no objections or suggestions were received from any of the persons likely to be affected;
Now, therefore, in exercise of the powers conferred by Section 97 of the Employees’ State
Insurance Act, 1948 (34 of 1948), the Employees' State Insurance Corporation, do hereby makes the
following Regulations further to amend the Employees' State Insurance (General) Regulations, 1950,
namely :-
1. These Regulations may be called Employees’ State Insurance (General) (First)
Amendment Regulations, 2020.
2. In the Employees’ State Insurance (General) Regulation, 1950, the following changes
in Regulations and Regulation forms will be made.
(i) Insertion of Regulation 87 A : Notice of Commissioning Mother
An Insured Woman who wishes to have a child and get embryo implanted in any
other women shall give such notice in Form 17 amended to the appropriate branch
office by post or otherwise and shall submit together with Agreement of embryo
implantation executed between commissioning mother with the other woman.
(ii) Insertion of Regulation 88A: Declaration by Insured Women of her surviving
child or children
Insured Women claiming maternity benefit before confinement or after confinement
or miscarriage shall submit the declaration of her surviving child or children. In case6 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III—SEC. IV]
Insured woman giving birth to more than one child such claim shall be treated a
single claim, however, for the next confinement the number of surviving children
should be counted as per the actual number of surviving children at the time of
claiming maternity benefit.
(iii) Insertion of 89 C : Claim for Maternity Benefit by Commissioning Mother
Regulation 89 C Every Commissioning mother who as biological mother wishes to
have a child and prefers to get embryo implanted in any other woman, claiming
maternity benefit shall submit to the appropriate office by post or otherwise a claim
for maternity benefit in Form 19 (Amended) together with copy of agreement on non-
judicial stamp paper between commissioning mother and the other woman to whom
embryo implantation is intended, copy of certificate issued by Assisted Reproductive
Technology Clinic and copy of birth certificate issued by the authority under the
Registration of Births & Deaths Act, 1969.
Provided further that if commissioning mother and the other woman both are Insured
Women, the claim will be provided only to the commissioning mother. Claim against
miscarriage will not be payable to the commissioning as well as to the other woman.
(iv) Insertion of 89 D Claim for Maternity Benefit by Adoptive Mother
Regulation 89 D Every Insured woman, who legally Adopts a child of upto 3 months
of age, claiming maternity benefit shall submit to the appropriate office by post or
otherwise a claim for maternity benefit in (Form 19 Amended) together with copy of
the court order/Certificate from Registrar and birth certificate issued by the Authority
under the Registration of Births & Deaths Act, 1969 incorporating the name of
adoptive parents or single Insured woman who legally adopts a child and copy of the
Adoption Order issued by the Competent Court.
In case of annulment of adoption approved by the court Insured Woman will refund
maternity benefit received by her.
(v) Regulation Revised Form no. 17 and Form no. 19 as notified vide No. N-
11/13/2/2003 – P&D dated 01.10.2004 and published in the Gazette of India
(Part-III Section-4) dated 23rd October, 2004, shall be substituted by revised
forms as annexed to this notification of Draft Regulations.
3. They shall come into force on publication of final notification in the Gazette of India.
[ADVT.-III/4/Exty./31/2020-21]
A.K.SINHA,Insurance Commissioner
[FORM 17]
CERTIFICATE/NOTICE OF PREGNANCY
MATERNITY BENEFIT
(Regulation 87& 87A)
EMPLOYEES’ STATE INSURANCE CORPORATION
Signature or thumb-impression
Of the Insured Woman
Employer’s Code No. ……………………………. Book No…………………………
Insured Woman’s Name………………………….. Serial No…………………………
Insurance No …………………………………………..
Stamp of the Dispensary[भाग III—खण् ड 4] भारत का रािपत्र : असाधारण 7
Certified that I have examined the above mentioned Insured Woman and that in my opinion
she is pregnant and her pregnancy appears to be……………………….weeks old.
Or {proposed to be incorporated)
Certified that I have examined the original Agreement of embryo implantation executed
between commissioning mother with the other woman. I have also examined certificate of embryo
implantation issued by the Assisted Reproductive Technology Clinic recognized by Indian Council
of Medical Research.
Date………………………….. ……………………………
Signature of Counter-signature of Insurance Medical Officer
…………………………………
Name in Block Letter and
Rubber Stamp
Any other Remarks……………………………………….
I, …………………………………………… Insurance No. ………………………………
wife/daughter of …………………………………………… hereby give notice of pregnancy.
Or
I, …………………………………………… Insurance No. ………………………… wife/daughter of
…………………………………………… hereby submit the copy of agreement for commissioning.
Present address
………………………………………………………………………………………………
Present/last employer………………………………………………………………………………..
Date………………………………………
……………………………………………..
Signature or thumb-impression
of the Insured Woman
FORM 19
CLAIM FOR MATERNITY BENEFIT AND NOTICE OF WORK
[Existing Regulations {88 (ii), 89 & Regulation 91},
New Added Regulation {{88(iv), 89(C), and 89(D)}}
EMPLOYEES’ STATE INSURANCE CORPORATION
Signature of thumb-impression
Of the Insured woman
Book No…………………..
Serial No………………….
Employer’s Code No……………………….
Insured Woman’s Name………………….
Insurance No…………………………………8 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III—SEC. IV]
Wife/Daughter of ………………………….
Stamp of the Dispensary
I, the above mentioned Insured Woman hereby claim Maternity Benefit for expected
confinement or confinement* or miscarriage of self or commissioning mother or Adopting mother
with effect from…………………………
I, further declare that I have ceased*/shall cease to work for remuneration with effect from the
aforesaid date.
*I, do hereby give notice that I have taken up/shall take up work for remuneration with effect
from the ………………..I have drawn maternity benefit only upto…………………………….
*** I hereby declare that as on date I have the following child/children and I do hereby
declare that the information furnished is true and nothing has been concealed.
Sl. No. Name of IW Gender Date of birth
First Child
Second Child
Third Child
Forth Child
Present/last employer**…………………………
Department, shift and occupation……………
Present address…………………………………….
Signature or thumb-impression of the Insured Woman
Date…………………… Name of the Branch
Office………………………………
* Please delete whichever not applicable
** If not in employment, mention the particulars of last employer.
*** The above declaration is not applicable for commissioning mother & adoptive mother.
IMPORTANT:-
1. No work for remuneration shall be taken up during the period for which Maternity
Benefit is claimed or is to be claimed.
2. For resumption of work must be sent before any work is taken up.
3. If Commissioning mother and other woman both are Insured Woman then the claim
will be provided only to the commissioning mother. Claim against miscarriage will
also not be payable to the commissioning as well as to the other woman.
4. In case annulment of adoption approved by the Court, Insured Woman shall refund
the entire amount of maternity benefit paid to her.
5. In case Insured woman gives birth of twin child such claim shall be treated a single
claim.
6. A person who makes a false statement or representation for the purpose of obtaining
benefit, whether for himself or for some other person, commits an offense punishable
with imprisonment for a term which may extend up to six months, or with a fine up to
Rs. 2,000/- or with both.
Uploaded by Dte. of Printing at Government of India Press, Ring Road, Mayapuri, New Delhi-110064
and Published by the Controller of Publications, Delhi-110054.