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ESI Form2
ESI Form2
PART – A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned below
to receive the amount standing to my credit in the Employees Provident Fund, in the event of my death.
If the nominee is minor
Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee
1 2 3 4 5 6
1 *Certified that I have no family as defined in para 2 (g) of the Employees Provident Fund Scheme 1952 and should I
acquire a family hereafter the above nomination should be deemed as cancelled.
PART – (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive Widow/Children Pension in the
event of my premature death in service.
Sr. No Name & Address of the Family Member Age Relationship with the member
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the
event of my death without leaving any eligible family member for receiving pension.
Date ___________________
____________________________________________________________________________________________________________
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri / Smt./
Miss_________________________________________________________________ employed in my establishment after he/she has
read the entries / the entries have been read over to him/her by me and got confirmed by him/her.
Place :
Name & address of the Factory /Establishment
Date :