The name of the dispensary or doctor where treatment is sought.
No. ESIC accepts only online filing or, in rare cases, a signed PDF. Use Word only for drafting. esic form 105 word format
ESIC Form 105 , also known as the Certificate of Entitlement The name of the dispensary or doctor where
[HEADER: EMPLOYEES' STATE INSURANCE CORPORATION] Form 105 (Revised) Month/Year of Contribution: _____________ Employer Code: _____________ Use Word only for drafting
| Field | Description | |-------|-------------| | | ESIC employer code (17 digits) | | Month & Year | e.g., January 2026 | | Total number of employees | Subhead: “No. of employees on the last day of the month” | | Total wages bill | Gross wages paid in that month | | Employee’s contribution | 0.75% of wages (general employees) or 0.375% (if wage ≤ ₹137/day) | | Employer’s contribution | 3.25% of total wages | | Total contribution | Sum of employee + employer share | | Date of payment | Challan payment date (online via ESIC portal) | | Declaration | Signature of employer/authorized signatory |