The Social Security (Central) Rules, 2026

Rule Form XI Form XI

Chapter: Annexures · Forms and Appendices
Text as on: As notified 08 May 2026

FORM -- XI [See rule 35 (2)(a) and (c)]

(Notice of claim for maternity benefit and payment thereof under sections 62 and 63)

To ...................... (name of establishment)

PART I [See Rule 35 (2)(a)]

Notice I ............. (name of woman) wife or daughter of...... employed as...... at.........(name of establishment), hereby give notice that I expect to be confined within six weeks next following from the date of this notice or have given birth to a child on.....(date) and shall be absent from work from.....(date). I shall not work in any establishment during the period for which I receive maternity benefit.

2.For the purpose of section 63, I hereby nominate......... (Here enter name and address of the nominee) to receive maternity benefit and/ or any other amount due to me under the Code in case of my death.

Signature of an Attester in case Signature or thumb impression of woman

the woman is not able to sign

and affix thumb impression.

Date............

PART II

[See rule 35 (2)(c)]

FORM OF RECEIPT OF MATERNITY BENEFIT

I,......, the undersigned, a woman employee/ the nominee of...... woman employee or legal

representative of...... woman employee deceased in......(name of establishment) at...... in......

district received maternity benefit and/or other amount due under the Code on Social Security

,2020(36 of 2020) from the employer of the establishment referred to above, as detailed below:-

Rs...... being the first installment of maternity benefit paid on......

Rs...... being the second installment of maternity benefit after delivery paid on......

Rs...... being the medical bonus under section 64 of the Code paid on......

Rs......being the wages for the leave period from...... to...... mentioned under section 65.

*My/ Her confinement/ miscarriage or Medical termination of pregnancy or tubectomy operation

took place on.......or I/she fell ill because of pregnancy, delivery, premature birth of a child or

miscarriage or Medical termination of pregnancy or tubectomy operation on............ In consequence

I...... her nominee/legal representative has received the aforesaid amounts prescribed in sections 60,

64 and 65 of the Code on Social Security, 2020(36 of 2020).

Signature or thumb impression of......... *Woman employee or her nominee or legal representative

Signature of an Attester in case the woman is not able to sign and affixes thumb impression

Place: Date: *Strike out unnecessary portion.

FORM -- XI
[See rule 35 (2)(a) and (c)]

(Notice of claim for maternity benefit and payment thereof under sections 62 and 63)

To
...................... (name of establishment)

PART I
[See Rule 35 (2)(a)]

Notice
I ............. (name of woman) wife or daughter of...... employed as...... at.........(name of
establishment), hereby give notice that I expect to be confined within six weeks next following from
the date of this notice or have given birth to a child on.....(date) and shall be absent from work
from.....(date). I shall not work in any establishment during the period for which I receive maternity
benefit.

2.For the purpose of section 63, I hereby nominate......... (Here enter name and address of the
nominee) to receive maternity benefit and/ or any other amount due to me under the Code in case of
my death.

Signature of an Attester in case           Signature or thumb impression of woman