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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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