EMPLOYEES’ STATE INSURANCE CORPORATION ORIGINAL

Challan Form for Deposit in A/c No. 1 For Bank

Employer’s Code
Region code Employer code Industry Date Month Year
Code

Bank & Branch Code*

Name of Factory
/ Estt. & Address

Mode of Payment [Tick ()]

Cash Cheque/D.D.No. Dated:
Cheque Drawn on (Name of the Bank/Branch)
D.D.

Period of contribution Month Year

Nature of Payment [Tick ()] Regular Contribution Interest Damages
Others

Total Wages : Rs.

No. of Employees:
Rs. Ps.
Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………
Total amount (in words)
____________________________________________________________________________________
R.O. Demand Letter No. & Date __________________________________________________________
______________________________________
Ban Signature
k ______________________________________
Seal
Name & Designation – Seal of Authorised Signatory
____________________________________________________________________________________
Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________

Received Rs. For use in Bank

(Rs…………………………………………………………………..only) Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to Date: ……………………………….
Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1 Authorised signature & Seal of the Receiving
Bank

*(For Bank Branch Code see on reverse) Important: Affix Correct Code No. Name Seal
and Period of contribution to avoid missing credit
 EMPLOYEES’ STATE INSURANCE CORPORATION DUPLICATE
Challan Form for Deposit in A/c No. 1 For ESIC through Bank

Employer’s Code
Region code Employer code Industry Date Month Year
Code

Bank & Branch Code*

Name of Factory
/ Estt. & Address

Mode of Payment [Tick ()]

Cash Cheque/D.D.No. Dated:
Cheque Drawn on (Name of the Bank/Branch)
D.D.

Period of contribution Month Year

Nature of Payment [Tick ()] Regular Contribution Interest Damages
Others

Total Wages : Rs.

No. of Employees:
Rs. Ps.
Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………
Total amount (in words)
____________________________________________________________________________________
R.O. Demand Letter No. & Date
____________________________________________________________________________________
______________________________________
Ban Signature
k ______________________________________
Seal
Name & Designation – Seal of Authorised Signatory
____________________________________________________________________________________
Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________

Received Rs. For use in Bank

(Rs…………………………………………………………………..only) Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to Date: ……………………………….
Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1 Authorised signature & Seal of the Receiving
Bank

*(For Bank Branch Code see on reverse) Important: Affix Correct Code No. Name Seal
and Period of contribution to avoid missing credit
 EMPLOYEES’ STATE INSURANCE CORPORATION TRIPLICATE
Challan Form for Deposit in A/c No. 1 For Depositor

Employer’s Code
Region code Employer code Industry Date Month Year
Code

Bank & Branch Code*

Name of Factory
/ Estt. & Address

Mode of Payment [Tick ()]

Cash Cheque/D.D.No. Dated:
Cheque Drawn on (Name of the Bank/Branch)
D.D.

Period of contribution Month Year

Nature of Payment [Tick ()] Regular Contribution Interest Damages
Others

Total Wages : Rs.

No. of Employees:
Rs. Ps.
Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………
Total amount (in words)
____________________________________________________________________________________
R.O. Demand Letter No. & Date
____________________________________________________________________________________
______________________________________
Ban Signature
k ______________________________________
Seal
Name & Designation – Seal of Authorised Signatory
____________________________________________________________________________________
Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________

Received Rs. For use in Bank

(Rs…………………………………………………………………..only) Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to Date: ……………………………….
Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1 Authorised signature & Seal of the Receiving
Bank

*(For Bank Branch Code see on reverse) Important: Affix Correct Code No. Name Seal
and Period of contribution to avoid missing credit
 EMPLOYEES’ STATE INSURANCE CORPORATION QUADRUPLICATE
Challan Form for Deposit in A/c No. 1 For Depositor to be attached
with Return of contributions
Employer’s Code
Region code Employer code Industry Date Month Year
Code

Bank & Branch Code*

Name of Factory
/ Estt. & Address

Mode of Payment [Tick ()]

Cash Cheque/D.D.No. Dated:
Cheque Drawn on (Name of the Bank/Branch)
D.D.

Period of contribution Month Year

Nature of Payment [Tick ()] Regular Contribution Interest Damages
Others

Total Wages : Rs.

No. of Employees:
Rs. Ps.
Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………
Total amount (in words)
____________________________________________________________________________________
R.O. Demand Letter No. & Date
____________________________________________________________________________________
______________________________________
Ban Signature
k ______________________________________
Seal
Name & Designation – Seal of Authorised Signatory
____________________________________________________________________________________
Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________

Received Rs. For use in Bank

(Rs…………………………………………………………………..only) Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to Date: ……………………………….
Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1 Authorised signature & Seal of the Receiving
Bank

*(For Bank Branch Code see on reverse) Important: Affix Correct Code No. Name Seal
and Period of contribution to avoid missing credit
 FOR OFFICE USE ONLY

Posted in Page No. ………………………. Vol. No………..……

Posted by Checked by Supdt/B.O.

 List of the designated Branches of Banks for collection of ESI Contribution

Sl.No Name of the Bank Code No. of Sl.No Name of the Bank Code No. of
the Bank the Bank
1 Banashankari II Stage 6767 50 Chennamma Nagar Belgaum 7862
2 Basavanagudi 3357 51 Bellary 817
3 Byatarayanapura (Mys.Road) 7985 52 Bijapur 819
4 Cauvery Bhavan 3182 53 Channapatna 7032
5 City Market 1989 54 Chitradurga 5618
6 Doorvaninagar 1438 55 Davanagere 5624
7 Electronic City 9044 56 Doddaballapur ADB 5313
8 H.A.L. 1114 57 Dharwad 833
9 U.A.S. Hebbal 1316 58 Gadag 838
12 Hoskote ADB 1808 59 Gulbarga 3304
11 Indiranagar 3301 60 Gokak 840
12 Jalahalli 963 61 Harihar 7914
13 Jayanagar IV Block 4926 62 Hassan 5622
14 Bangalore City Br. (J.C.Road) 814 63 Hospet 763
15 Kumarapark 1626 64 Hubli 846
16 Magadi Road 9047 65 Mandya 3916
17 ITI Anc. Ind. Est Mahadevpura 3028 66 Lalbaug-Mangalore 4928
18 Malleswaram 7080 67 Panambur-Mangalore 2249
19 New Tharagupet 5794 68 Hampanakatta-Mangalore 5791
20 Peenya Indl. Estate 3024 69 Silver Gate – Mangalore 7983
21 Rajajinagar Indl. Estate 762 70 Munirabad 5316
22 Rajajinagar V Block 3023 71 Mysore Main 3130
23 Richard Town 2263 72 S.K.S. Branch-Mysore (Mysore 7968
SSI Branch)
24 Shivajinagar 3298 73 Belavadi Indl. Mysore 6768
25 Bangalore Br. (St.Marks Road) 813 74 Mysore South (Chamundinagar) 7346
26 West of Chord Road 6497 75 Nanjangud 7916
27 Wilson Garden 4932 76 Nargund 2240
28 Yeshwanthpur 3297 77 Nippani 888
29 SBI Aircargo Complex 7130 78 Raichur 4622
30 Bidadi 4235 79 Bankur Indl. Est.Shahabad 7572
31 Rajajinagar Commercial Br. 4230 80 Shimoga 5619
32 Doddaballapur Byashattihalli 8988 81 Tumkur 3917
33 J.P. Nagar 7117 82 Udupi 945
34 Karkala (SBM) 4151 83 Yadgir – ADB 3764
35 Kadugodi (SBI) 5376 STATE BANK OF MYSORE
36 Kumara Park SSI Branch 8577 84 Belagola 4247
37 Mysore Commercial Branch 4161 85 Chamarajanagar 4162
38 MICO Layout 9041 86 Coondapur 4150
39 Whitefield (SBM) 4023 87 Dandeli 4130
40 Ramanagar SBI 4998 88 Hunsur 4064
41 Bannerghatta Road 4407 89 Kanakapura 4029
42 ITPL 4456 90 K.G.F. BEML Nagar 4168
43 SSI Branch Peenya 6506 91 Kollegal 4065
44 Kacharakanahalli 7988 92 Puttur 4152
45 Wheel & Axel Plant Yelahanka 6706 93 Ramanagar 4031
OUT STATION 94 T. Narasipur 4076
46 Bagalkot 812 STATE BANK OF HYDERABAD
47 Banhatti 4757 95 Sedam, Gulbarga District 2235
48 Belgaum (Main) 816
49 Indl. Estate Belgaum 2217