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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 abovenamed 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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