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ESIC Nomination Form
ESIC Nomination Form
in
M/U/W
7. Present Address
______________________
6.Sex
M/F
8. Permanent Address
______________________
______________________
______________________
______________________
______________________
______________________
______________________
Pin Code
Pin Code
e-mail address
e-mail address
Branch Office
Dispensary
e-mail address
(C) Details of Nominee u/s 71 of ESI Act 1948/Rule 56(2) of ESI (Central) Rules, 1950 for
payment of cash benefit in the event of death.
Name
Relationship Address
I hereby declare that the particulars given by me are correct to the best of my knowledge and belief. I
undertake to intimate the Corporation any changes in the membership of my family within 15 days of such
change.
Counter signature by the employer
Signature/T.I.of IP
Signature with Seal
(D) FAMILY PARTICULARS OF INSURED PERSON
Sl.
No.
Name
Relationship with
the Employee
Whether
residing with
him/her?
Yes
No
Town
State
1.
2.
3.
4.
5.
6.
..
ESI Corporation
Temporary Identity Card
Name
Ins.No.
Date of appointment
Branch Office
Dispensary
1.
Signature/T.I. of I.P
Signature of B.M. with Seal
Submission of Form-1 is governed by regulations 11 & 12 of ESI (General) Regulations, 1950.
2.
Family means all or any of the following relatives of an Insured Person namely:-
(i) A spouse (ii) a minor legitimate or adopted child dependant upon the I.P;(iii) a child who is wholly
dependant on the earnings of the I.P. and who is (a)receiving education, till he or she attains the age of
21 years (b)an un married daughter; (iv) a child who is infirm by reason of any physical or mental
abnormity or injury and is wholly dependant on the earnings of the I.P. so long as the infirmity
continues; (v) dependant parents (Please see Section 2 clause 11 of the ESI Act 1948 for details).
3.
4.
5.
Submission of false information attracts penal action under Section 84 of ESI Act, 1948.
6.
This form duly filled in must reach the concerned Branch office within 10 days of appointment of an
Employee. Delay attracts penal action under Section 85 of the Act, against employer.
7.
As an Insured person you and your dependent family members are entitled to full medical care. The
other benefits in cash include (1) sickness Benefit (2) Temporary Disablement benefit (3) Permanent
disablement Benefit (4) Dependents benefit and (5) Maternity Benefit (incase of women employees
subject to fulfillment of contributory conditions.
8.
For more details Please Visit website of ESIC at WWW.esic.nic.in or www.esickar.gov.in contact
Regional office or Branch Office.
___________________________________________________________________________________
FOR BRANCH OFFICE USE ONLY
1. Date of Allotment of Ins. No. _______________________________________________________
2. Date of issue of TIC : _____________________________________________________________
3. Name/ No. of Disp : ______________________________________________________________
4. Whether reciprocal Medical arrangements involved? If yes, please indicate : __________________
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Sl.
No.
1
2
3
4
5
6
Name
Date of Birth/Age
as on date of
filling form
Relationship
with the
Employees
Whether
residing with
him/her?
Yes
No
State