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ANNEXURE-A
PROFORMA FOR WITHDRAWAL OF COURT CASES
1. Name and address of the Insured person/employer
] 1. Employer Code No./lnsurance No.
]U. Date of Institution of case
IV. Name of the Court/Forum in which case is pending
\'. Section of ESIAct 1948 under which the case was filed.
\ 'I. Present status of the case and the issues involved
\ U. Details of amount involved with period.
Compliance made Nature of default S.No.
V1]1. Copy of court order permitting out of court settlement in case of
litigation u/s 75 and appeal u/s 82 of the Act.
D::. Proof & Details of deposit of the amount.
The above information is true and correct to the best of my
kuowledqe, I also undertake that I shall be regular in compliance in the
pi ovisions of ESIAct in future or else shall forfeit the right to a avail of
Sl ch Amnesty scheme.
Date:
PI:ICe:
Signature of the Applicant
Name:
Status: