Signature of the S.S.O

C-10 (B)

EMPLOYEES’ STATE INSURANCE CORPORATION

INSPECTION REPORT

Code No. Category Regio Inspection Division n 2(12)/1(5) Name Address Telephone & Mobile Bankers Name & Name (s) of Social Security No./E-mail of the Employer Bank A/c. No. Officer

Details of Movable/Immovable Date of Period Covered property of Factory/Establishment Inspection/Date of Allotment Period Period Period Pending for Selected for Inspection for which inspection Book of Account Verified

Exact Nature of Mfg. process Date of Last Period Covered work/Business carried on/Activity Inspection Period Period Period Pending for Selected for Inspection for which inspection Book of Account Verified

Branch Office to which attached

Name & Designation of person contacted for Inspection & to whom discrepancy detected was communicated

1. Name, Father’s Name and Residential Address of Principal Employer (Indicate change with date, if any, since last Inspection, please also obtain and furnish information with documentary evidence.) Owner or Occupier Manager

2. Particulars of Immediate Employer(s), if any:- Nature of work performed Sl. No. Name and Address with At premises Outside premises Code No. (if registered with (Factory/Estt./Shop under the ESIC) supervision of Principal Employer or his agent

3. Connected office (s) etc. at the same station or elsewhere (including non-implemented areas), if any S.No. Name Address Nature of work Place of compliance and 17 - digit Sub Code No.

4. No. of Employees found working on the Date of Inspection

Employer Covered Not Covered Coverable but not covered

Principal

Immediate

Total 5. (a) Do Wage Rolls include all type of wage as defined under the Act?

(b) If not, is employer maintaining any other record to exhibit wages in addition to those accounted for in wage Rolls ? specify

6. Whether employer is maintaining all records & registers as required under ESI Act, 1948 & rules & regulation made thereunder? If not give details.

7. Have all coverable employees been correctly accounted for in Wage Rolls/Employees Register for payment of contribution? If not, furnish details.

8.Total Period (s) Total * Number Type of Omitted Reference to Amount of amount of of Wages Employer’s Contribution Unaccounted employees record where dues on wage wages depicted in Col.2 1 2 3 4 5 Employees’ Share

Employer’ Share

9 (a) Period for which Books of Account produced (b) Month (s) for which all Payment vouchers checked

10 Have Books of Account been checked for all types of Wages whether paid through Wages Rolls, Subsidiary Payment Records such as payment vouchers etc.

11. Has employer made compliance against outstanding arrears, of contribution Interest & damages and rectified discrepancies/irregularities pointed out as a result of Last Inspection? If compliance is not made, reasons thereof. 12. Details of Records Inspected and signed (also indicate Ledger Folio Page No. Month etc. of the records where the Social Security Officer) puts his Signature

* Give details including Name. Father’s Name designation, Monthly salary

PART – B (BENEFIT)

1. No. of Declaration Forms found not submitted on the date of visit. (Details to be given separately) 2. (a) No. of TIC/Pechan Cards found not delivered to the Employees. (Details to be given separately) (b) No. of Pechan Cards not received after capturing of Biometeric details. (Details to be given separately) (c) No. of employees whose Biometeric data not captured with in 15 days.

3. Details of present status of pending complaint/grievances, timely medical care & Long Term Benefit cases on the date of visit of SSO (Details to be given separately) 4. Whether accidents cases as reported to ESIC are reported to Factory Inspector/ Chief Inspector of Factories (if applicable)

5. Any suggestion from Employer/Trade Union/Employee (Details to be given separately) 6. Specify whether any court cases are pending under section 75/85 of the Act against this Employer.

Any other Points to be given by SSO

Signature of the S.S.O Date of Inspection Report EMPLOYEES’ STATE INSURANCE CORPORATION

TEST INSPECTION REPORT

1. Name, Address and Code No. of the Factory/Establishment

2. Details of Inspection by Social Security Office/Test Inspection Officer. SSO TIO a) Name b) Date of Inspection c) Period of Inspection d) Period of Ledger Verification e) Month for which vouchers/Bills verified Thoroughly 3. Indicate change in ownership of the unit if any after the date of Inspection by SSO.

PART – A – CONTRIBUTORY DETAILS

Covered Exempted Coverable but not covered 1. No. of Employees on the date of visit a) Principal Employer b) Sales Office/Branch Offices c) Through Contractors independently covered d) Through Contractors covered under Code No. of Principal Employer 2. A) Components of wages found as per the salary/wage registers and ledger verification Details of wages Whether considered for payment of contribution or not 1 2 3 4 B) Please furnish full details of wage component as detailed above which ought to have been considered for contributions but not considered or vice versa: C) Whether the SSO exercised the diligence on such wages in his report and if not remedial measures suggested.

*D) The Test Inspection Officer should indicate whether the omission by SSO is willful negligence with malafide or bonafide error/omission with reasons.

* M E) Findings on the compliance by the Contractor 1 Name of the Contractor 2 Nature of work done 3 Whether the job is done inside premises or outside 4 Period of contract 5 Total contractual amount 6 No. of Employees engaged 7 Contributions paid 8 Percentage of contributions paid vis- à-vis contractual amount 9 Remarks of the TIO with reference to compliance F) Please also indicate whether the report of SSO with reference to Supervisory control or absence of it with reference to employees engaged through contractors outside factory premises is in order or not if not give full details.

PART – B (BENEFIT)

1. No. of Declaration Forms found not submitted on the date of visit. (Details to be given separately) 2. (a) No. of TIC/Pechan Cards found not delivered to the Employees. (Details to be given separately) (b) No. of Pechan Cards not received after capturing of Biometeric details. (Details to be given separately) (c) No. of employees whose Biometeric data not captured with in 15 days.

3. Details of present status of pending complaint/grievances, timely medical care & Long Term Benefit cases on the date of visit of SSO (Details to be given separately) 4. Whether accidents cases as reported to ESIC are reported to Factory Inspector/ Chief Inspector of Factories (if applicable)

5. Any suggestion from Employer/Trade Union/Employee (Details to be given separately) 6. Specify whether any court cases are pending under section 75/85 of the Act against this Employer. PART – C (MISCELLANEOUS)

1. Comment on the reliability of the records produced by the Employer for inspection 2. Please indicate whether marking of this case for inspection by RO/SRO and conducting of such inspection by SSO is in tune with the inspection policy of Hqrs. or not. 3. Details of records inspected and signed by (a) SSO

(b) Test Inspection Officer

4. Date of allotment of Test Inspection

Any other Points to be given by T.I.O

* Mandatory

Name & Signature of the T.I.O