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Form guide · Source checked 21 October 2026
ESIC Form 9: claim for sickness or temporary disablement benefit
The insured person’s cash-benefit claim, supported by genuine medical certificates; distinguish ordinary sickness, temporary disablement and maternity-related sickness.
Identified 1950 Regulations form / saved transition and online procedure; checked 21 October 2026
Download and read the completed example
Completed fictional claim for sickness or temporary disablement benefit for Illustration Office Services Pvt Ltd (fictional), 14 Example Park, New Delhi 110001. Synthetic identifiers cannot be used for filing or medical care.
Fictional, unsigned completed illustration. It demonstrates this form’s fields; it is not a filed return, medical opinion, official order or proof of an actual transaction.
When and how this form is used
Regulation63 requires Form9 with the appropriate medical certificate. One claim can cover more than one accompanying certificate; it does not remove the certificate submission deadlines.
The maternity wording concerns sickness arising out of pregnancy/confinement/premature birth/miscarriage under Regulation89-B. Ordinary maternity-benefit notice/claim is the separate Form19 route. Do not label Form9 as the sole form for all maternity benefits.
The employer’s abstention verification is separate Form10 under Regulation52-A. The claimant must disclose actual paid leave, holidays and work; no automatic payout or cash-benefit amount follows merely from filling this sample. Qualifying contribution history and ESIC adjudication are not assumed proven.
The paper form shows cash/money-order preferences; Regulation110 governs introduced online submission/payment procedures. Use genuine verified payment details and actual portal instructions.
The completed fields
Claim identity and selected declarations
| Prescribed field / section | Completed fictional entry |
|---|---|
| Name / parent / insurance | Ravi Kumar, son of Meera Kumar; [synthetic IP DEMO-0001; not a valid insurance number] |
| Selected branch / abstention start | Ordinary sickness; not worked since1 October2026; temporary-disablement and maternity-related sickness alternatives not selected |
| Claimed period / certificate schedule | 1–15 October2026 inclusive; first certificate1 October, intermediate8 October, final15 October with fitness16 October; actual certificates required |
| No longer sick / resumption | No longer claims sickness from16 October2026; no remunerated work before that date |
| Wages / leave / holiday declaration | No wages received for any claimed day, including leave/holiday/weekly-off days, on these hypothetical facts; any later wage payment must be truthfully reconciled |
| Strike declaration | Not on strike during the certified abstention1–15 October2026 |
| Payment preference field | Historical paper choice: cash at Branch Office selected; money order not selected. Actual online claim/payment coordinates follow the ESIC specified route, not synthetic account credentials |
| Signature / name / date | Ravi Kumar; New Delhi,16 October2026; Unsigned fictional teaching entry; signature, seal, photograph attestation and official issue NOT executed |
Supporting records and reconciliation
Actual identity, timely first/intermediate/final medical certificates, benefit-period and contribution eligibility record, claim submission, employer abstention/wage verification and true payment particulars.
Worked calculation: Claimed calendar span1–15 October=15 days; this is a certified-span illustration, not15 automatically payable benefit days.
Official source and version
Download the official source pages containing this form. Adjacent prescribed forms can share a source page; use the heading and rule identified above.
These are the identified ESI (General) Regulations 1950 forms and the online procedures described by ESIC. Code on Social Security section164(2)(b) saves the earlier ESI rules/regulations for one year from commencement to the extent consistent. The 13 July 2026 instrument published in Gazette274902 is expressly a DRAFT inviting objections; it cannot by itself substitute these forms. The examples are source-checked on 21 October 2026 within the identified transition, not a claim that an old paper layout is the current portal screen.
Practical questions
Can I submit the sample as my own completed form?
No. Replace the fictional facts with accurate records, use the competent filing or record-keeping route described above and complete genuine signatures or certifications where required.
What makes the example specific to this form?
The insured person’s cash-benefit claim, supported by genuine medical certificates; distinguish ordinary sickness, temporary disablement and maternity-related sickness.