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Esic Form 37

The document is an application for medical treatment acceptance by an insured person with Dr. ____________, with whom they were already registered. It refers to a certificate of employment on the reverse side and requests acceptance for treatment. The doctor signs accepting the insured person whose particulars are given on the reverse side onto their list.

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Umesh C
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20K views1 page

Esic Form 37

The document is an application for medical treatment acceptance by an insured person with Dr. ____________, with whom they were already registered. It refers to a certificate of employment on the reverse side and requests acceptance for treatment. The doctor signs accepting the insured person whose particulars are given on the reverse side onto their list.

Uploaded by

Umesh C
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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fpfdRlk dh LohÑfr ds fy, izkFkZuk&i=k ,fldµ esfM&7,

Application for acceptance for medical treatment ESIC-MED 7A

ihB i`"B ij fn, gq, fu;kstu ds izek.k&i=k ds lanHkZ esa fpfdRld--------------------------------


--------------------------}kjk LohÑfr ds fy, fuosnu djrk gwa fd ftuds lkFk eSa igys gh iathÑr FkkA
With reference to certificate of employment on the reverse I apply for acceptance
by Dr......................................................................... with whom I was already registered.

fnukad--------------------------------- chekafdr O;fDr ds gLrk{kj ;k vaxwBs dk fu'kku


Dated Signature or Thumb impression of the
insured person

eSa bl O;fDr ftldk C;kSjk ihNs fn;k x;k gS fd viuh lwph esa lfEefyr djuk Lohdkj djrk gwaA
I accept the person whose particulars are given on reverse on my list.

fnukad------------------------------------ fpfdRld ds gLrk{kj rFkk dwV la[;k


Dated Signature and Code No.
of the Doctor

deZpkjh jkT; chek fuxe ,fldµ esfM&37


EMPLOYEES' STATE INSURANCE CORPORATION ESIC-MED 37
iqufuZ;kstu@fujUrj fu;kstu dk izek.k i=k
Certificate of Re-employment, continuing Employment.
¼rc tkjh fd;k tk;s tc fd fuEufyf[kr 'krZ½ (i) vkSj (ii) dh larqf"V gks½
(To be issued only if condition (i) or (ii) below are satisfied)
fu;kstd dk uke vkSj irk-------------------------------------------------------------------------------------------------
Name & Address of the Employer.
--------------------------dwV la[;k@Code No.
izekf.kr fd;k tkrk gS fd Jh Certified that Shri.......................................................................
iq=k Jh S/o.........................................................................chekad Ins. No..........................
(i) has continued to be in employment/re-entered insurable employment on...................................
and contrbution have been payable/paid in respect of him/her during the contribution period which
began on.............................
(ii) has paid contributions for seventy eight days in the preceding contribution period which ended
on...................................
fnukad Date................................. gLrk{kj vkSj in Signature & Designation
fVIi.kh & ;g izek.k&i=k mi;qZDr (i) vkSj (ii) esa vafdr frfFk ls 9 ekl ds fy;s oS/k gSA
Note :- This certificate is valid for 9 months from the dates indicated under (i) or (ii) above.

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