Proforma for Coverage

(to be submitted by an employer along with one or more of the documents mentioned below for obtaining Code Number)
1. Name of the establishment/factory and address
2. Details of Head Office and branches with address
3. Details of Code No. if any allotted to the Head Office
4. Date of Incorporation/Set up (Please furnish any one of the documents mentioned overleaf in support of the proof of date of set up of the est./factory)
5. Employment Strength
(i) At present :
(ii)Month wise employment strength from the date of set up may be furnished in
separate statement :
6. Nature of business activity / manufacturing activity :
7. Details of legal set up of the establishment
(Please mention whether it is an incorporated Private or Public Limited Company, Society, Partnership or Proprietary concern) :
8. Details of the employers/ownership
particulars etc. (Names, Designation and
Addresses of Managing Director,
Directors, Partners, Secretary etc. to
be furnished) :
9. Wages disbursed for the month :
10. Details of Bankers: (Including Bank
Branches & Account Number (s).)
11. Income Tax Permanent A/c. No.
12. Details of employees are furnished below :-
S.No. Name of the employee Father’s Name Date of
Joining
Wages (basic +
D.A. & Cash
Value of food
concession)
1.
2.
3.
4.
5.
6.
7.
8.
9
10
11
12
13
14
15
16
17
18
19
20
21
(In case you have more than 21 employees the above information in
respect of the other employees may be added in a separate sheet of paper in the same format continuing the serial number.)
11. Details of bank draft amounting to the contribution. Name of the Bank &
And administrative charges paid in respect of the above . Branch
employees. (Rate of Contribution at present is 12% by .
employer and employees+ 0.5% towards E.D.L.I. . Draft No.& Date
contribution and 1.15% towards administrative charges) .
Amount
VERIFICATION
The details furnished above are correct to the best of our knowledge and
belief. It is clearly understood that we are liable for coverage from a date antecedent to the date of set up furnished above in the event of furnishing of false information.
(Signature)
Employer.
Essential Document(s) to be submitted (For other than a proprietary concern)
1. A copy of Memorandum and Articles of Association and the certificate of
incorporation issued by the Registrar of Companies, in the case of Public and
Private Ltd. Companies.
2. A copy of partnership deed in the case of partnerships.
3. A copy of Registration certificate issued by the Registrar of Co-operative
societies.
4. A copy of Registration certificate issued by Registrar in the case of societies
registered under Societies Registration Act along with a copy of the objects and Rules of the Society.
5. Partition deeds creating HUF.
6. Any agreement or other legal documents in the case of Association of persons
as defined in the Income Tax Act.
A list of documents which can be submitted as a proof of date of set up :-
(Any one of these documents has to be submitted)
1. First Sales Invoice.
2. Any proof regarding date of trial production.
3. Incorporation Certificate issued by the Registrar of Companies together
with the report of the Managing Director to the Shareholders in the Annual Report.
4. Commencement of Business Certificate issued by the Registrar of Companies.
5. Certificate of Registration issued by the Registrar of Co-operative Societies.
6. Certificate of Registration issued under Societies Registration Act.
7. Certificate issued by Reserve Bank of India registering newly set up and
non-banking financial companies.
8. License issued by the Health Authorities.
9. License/permission issued by the Municipal/Corporation Authorities.
10. Permission/approval granted by the appropriate State Govt. Authorities in
the case of Educational Institutions.
11. Certificate issued by the Fire Authorities in the case of establishments
coming under Explosives Act.
12. First assessment order issued by the Sales Tax Authorities.
13. First assessment order issued by the Income Tax Authorities.
14. Certificate issued by the Small Scale Industries authorities registering the
establishment.
15. Reports/returns to Central Excise authorities.
16. Sanction/connection of power like H.T. connection, L.T. connection etc.
17. Any other Certificate issued by any authority under any law for the time
being in force prior to the commencement of business activity/manufacturing activity.
The above list is not exhaustive and is only illustrative. Any one or more of the above documents may be submitted along with your application for allotment of a Code Number.