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EMPLOYEES’ STATE INSURANCE CORPORATION Form – 1

To be filled in by the employee after reading instructions mentioned on next page. Two Postcard Size photographs
are to be attached with this form. This form is free of cost.

(A) Insured Person’s Particulars (B) Employer’s Particulars

1. Insurance No. 9.Employer’s Code No.

2. Name (Block Letters) 10.Date of Joining DD MM YYYY

3. Father’s/Husband’s Name 11. Name & Address of Employer

CBRE South Asia Pvt. Ltd.
4. Date of Birth Marital Status Gender
19th Floor, DLF Square
DD MM YYYY M U W M F
M Block, Jacaranda Marg
● DLF City, Phase – 2
●
Gurgaon 122002
7. Present Address 8. Permanent Address 12. In Case of any previous employment, fill the details as under
(a)Insurance No.

(b) Employer Code

City City
State State (c) Email ID
Pin Code Pin Code:
Aadhar No. Name & Address of the Previous Employer
Personal Email ID
Mobile No.

(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 (with City, State & Pin Code)

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 (with seal) Employee’s Signature

(D) Family Particulars of the Insured

DOB/Age Relation Whether If no (Place of
S. No. Name Residing with Residence)
him/her
Yes No Town State
1
2
3
4
5
6
ESI Corporation (Valid for 3 months from the date of appointment) Temporary Identity Card

Name Date of Appointment (Joining)

Insurance Number
Branch Office Space for Photograph
Dispensary
Employer Code & Address CBRE South Asia Pvt. Ltd. 19th Floor, DLF Square, M Block,
Jacaranda Marg, DLF City, Phase – 2, Gurgaon 122002

Validity Dated: Signature/Thumb Impression of Employee Signature of BM with Seal

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Instructions for ESIC Nomination: -

1. 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) spouse (ii) a minor legitimate or adopted child dependent upon the I.P;(iii) a child who is wholly dependent on the earnings of the I.P.
and who is (a)receiving education, till he or she attains the age of21 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 dependent on the earnings of the I.P. so long as the infirmity continues; (v) dependent
parents (Please see Section 2 clause 11 of the ESI Act 1948 for details).

3. Identity Card is Non-transferable.

4. Loss of Identity Card be reported to Employer/Branch Manager immediately.
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 (in case 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

Date of Allotment of Ins. No

Date of issue of TIC :

Name/ No. of Dispensary :

Whether reciprocal Medical arrangements involved? If yes, please indicate

Signature of Branch Manager

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FORM 2 (Revised)

Nomination and Declaration Form for Unexempted/exempted establishments

Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme

Paragraphs 33 & 61 (1) of the Employees Provident Fund Scheme, 1952 and Paragraph 18 of the Employees’ Pension scheme,
1995)

Name (in Block letters)

Aadhar Number

Father’s/Husband’s Name

Date of Birth

Gender

Marital Status

Account Number

Permanent Address

Temporary Address

Date of Joining

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

Name of Address Nominee DOB Total amount If Nominee is a minor, name and
Nominee/Nominees Relation of share of relationship & address of the
with accumulations guardian who may receive the
member in Provident amount during the minority of the
Fund to be nominee
paid to each
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
2. *Certified that my father/mother is/are dependent upon me

*Strike out whichever is not applicable. Signature/Thumb Impression of the (Employee) Member/Subscriber

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Part – B (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 death

S. No. Name of the Family Address DOB Relationship with

member Member

1 2 3 4 5
1
2
3
4
5
6

** Certified that I have no family, as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and should I acquire a family hereinafter
I shall furnish particulars thereon in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2(a)(i) and (ii) in the event
of my death without leaving any eligible family member for receiving Pension

Name and Address of Nominee DOB Relationship with Member

1 2 3

Date Signature or Thumb Impression of the subscriber

**Strike out whichever is not applicable.

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by
Shri/Smt./Kum____________ __________________________ employed in my establishment after he/she has read the
entries/entries have been read over to him/her by me and got confirmed by him/her.

Place__________________ Signature of Employer/Authorized Officer of Establishment

Designation

Date___________________ Name & Address of the Factory/Establishment or rubber stamp thereon

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GUIDANCE FOR FILLING THE FORM No - 2

Employee’s Provident Fund Scheme, 1952 (EPF)

Para 33: - Declaration by persons already employed at the time of institution of the fund

Every person who is required or entitled to become a member of the Fund shall be asked forthwith by his employer
to furnish and shall, on such demand, furnish to him, for communication to the Commissioner, particulars
concerning himself and his nominee required for the declaration form in Form 2. Such employer shall enter the
particulars in the declaration form and obtain the signature or thumb impression of the person concerned

Para 61 - Nomination

1. Each member shall make in his declaration in Form 2, a nomination conferring the right to receive the amount
that may stand to his credit in the Fund in the event of his death before the amount standing to his credit has
become payable, or where the amount has become payable before payment has been made.
2. A member may in this nomination distribute the amount that may stand to his credit in the Fund amongst his
nominees at his own discretion.
3. If a member has a family at the time of making a nomination, the nomination shall be in favour of one or more
persons belonging to his family. Any nomination made by such member in favour of a person not belonging to
his family shall be invalid. Provided that a fresh nomination shall be made by the member on his marriage and
any nomination made before such marriage shall be deemed to be invalid.
4. If at the time of making a nomination the member has no family, the nomination may be in favour of any person
or persons but if the member subsequently acquires a family, such nomination shall forthwith be deemed to be
invalid and the member shall make a fresh nomination in favour of one or more persons belonging to his family.
4A. Where the nomination is wholly or partly in favour of a minor, the member may, for the purposes of this
scheme appoint a major person of his family, as defined in clause (g) of paragraph 2, to be the guardian of the
minor nominee in the event of the member predeceasing the nominee and the guardian so appointed. Provided
that where there is no major person in the family, the member may, at his discretion, appoint any other
person to be a guardian of the minor nominee.
5. A nomination made under sub-paragraph (1) may at any time be modified by a member after giving a written
notice of his intention of doing so in form 2. If the nominee predeceases the member, the interest of the
nominee shall revert to the member who may make a fresh nomination in respect of such interest.
6. A nomination or its modification shall take effect to the extent that it is valid on the date on which it is received
by the commissioner.

Para 2(g) – Family Means

i. In the case of a male member, his wife, his children, whether married or unmarried, his dependent
parents and his deceased son’s widow and children.

Provided that if a member proves that his wife has ceased, under the personal law governing him or the
customary law of the community to which the spouses belong, to be entitled to maintenance she shall no longer
be deemed to be a part of the member’s family for the purpose of this scheme, unless the member subsequently
intimates by express notice in writing to the commissioner that she shall continue to be so regarded; and

ii. In the case of a female member, her husband, her children, whether married or unmarried, her
dependent parents, her husband’s, dependent parents, her deceased sons widow and children;

Provided that if a member by notice in writing to the commissioner expresses her desire to exclude her husband
from the family, the husband and his dependent parents shall no longer be deemed to be a part of the member’s
family for the purpose of this scheme, unless the member subsequently cancels in writing any such notice.

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Explanation: - In either of the above two cases, if the child of a member [or as the case may be, the child of a
deceased son of the member] has been adopted by another person and if, under the personal law of the adopter,
adoption is legally recognized, such a child shall be considered as excluded from the family of the member.

EMPLOYEES PENSION SCHEME, 1 (EPS)

Para 18: Particulars to be supplied by the Employees already employed at the time of commencement of the
Employees’ Pension Scheme.

Every person who is entitled to become a member of the Employees’ Pension Fund shall be asked forthwith by his
employer to furnish and that person shall, on such demand, furnish to him for communication to the Commissioner
particulars concerning himself and his family in the form prescribed by the Central Provident Fund Commissioner.

Para 2(vii): - Family Means: -

i. Wife in the case of male member of the Employees’ Pension Fund;

ii. Husband in the case of a female member of the Employees’ Pension fund;
iii. and Sons and daughters of a member of the Employees’ Pension fund;

Explanation – The expression “Sons” and “daughters” shall include children (Legally adopted by the
member)

Note: Members can nominate a person to receive benefits under the Employees’ Pension Scheme 1995 where a
member is unmarried or does not have any family. Such nominee shall be paid pension equal to widow pension in
case of death of member.

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Form No. 11
(to be retained by the employer for future reference)

Employees’ Provident Fund Organization

Employees’ Provident Fund Scheme 1952 (Paragraph 34 & 57) & Employees’ Pension Scheme, 1995 (Paragraph 24)

(Declaration by the person taking up employment in any establishment on which EPF Scheme, 1952 and / or EPS 1995 is applicable)
1 Name of Member Rohit Patnala
2 Father’s Name (✔) Spouse’s Name ( )
(Please Tick whichever is applicable) P. Uma Shankar

3 Date of Birth (DD/MM/YYYY) 16/04/1994

4 Gender: (Male / Female/ Transgender) Male
5 Marital Status (Married/Unmarried/Widow/Widower/Divorcee) Unmarried
6 (a) Email ID [email protected]
(b) Mobile No. 9663535087
7 Whether earlier a member of Employees’ Provident Fund Scheme 1952 Yes ● / No
8 Whether earlier a member of Employees’ Pension Fund Scheme 1995 Yes ● / No
Previous Employment Details (if Yes to 7 and/or 8 above)
(a) Universal Account Number 100750613424
(b) Previous PF Account Number KDMAL009268100E044012
9 (c) Date of Exit from Previous employment (DD/MM/YYYY) 13/07/2021
(d) Scheme Certificate Number (if issued)
(e) Pension Payment Order (PPO) Number (if Issued)
10 (a) International Worker? No
(b) If Yes, state Country of origin (India/Name of other country)
(c) Passport Number L8685481
(d) Validity of Passport [(DD/MM/YYYY) to (DD/MM/YYYY)] 23/04/2024
11 KYC Details (attach Self Attested Copies of following KYC documents)
(a) Bank Account Number and IFS Code 50100361895230 HDFC0000594
(b) Aadhar Number 635315246772
(c) Permanent Account Number BYOPP0148R

Undertaking
1. Certified that the particulars are true to the best of my knowledge
2. I authorize EPFO to use my Aadhar for verification/authentication/eKYC purpose for service delivery
3. Kindly transfer the funds and service details, if applicable from the previous PF account as declared above to the present PF account (The
transfer would be possible only if the identified KYC detail approved by previous employer has been verified by the present employer
using his Digital Signature Certificate)
4. In case of changes in above details, the same will be intimated to the employer at earliest.

Date 09/07/2021 Signature of Member

Place Hyderabad

Declaration by Present Employer

The member Mr./Ms./Mrs. __________________________ has joined on ___________________ and has been allotted PF number __________
_________________________
In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
(Post Allotment of UAN) The UAN allotted for the member is __________________________________________________________________
Please tick appropriate option: The KYC details of the above member in the UAN database: -
( ) Have not been uploaded
( ) Have been uploaded but not approved
( ) Have been uploaded and approved with DSC

In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995
The above PF Account Number /UAN of the member as mentioned in (A) above has been tagged with his/her UAN/Previous Member ID as
declared by the member. Please Tick appropriate option:
( ) The KYC details of the above member in the UAN database have been approved with Digital Signature Certificate and
transfer request has been generated on portal
( ) As the DSC of the establishment are not registered with EPFO, the member has been informed to file physical claim
(Form 13) for transfer of funds from his previous establishment.

Date Signature of Employer with Seal of Establishment

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Form F [See sub-rule (1) of rule 6]

Nomination
To

CBRE South Asia Pvt. Ltd. 19th Floor, DLF Square, M Block, Jacaranda Marg, DLF City Phase – 2, Gurgaon – 122002

1. Rohit Patnala
I, (Name of the Employee) _______________________________________________ whose particulars are
given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable
after my death as also the gratuity standing to my credit in the event of my death before that amount has
become payable, or having become payable has not been paid and direct that the said amount of gratuity shall
be paid in proportion indicated against the name(s) of the nominee(s)
2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the meaning of clause (h)
of section (2) of the Payment of Gratuity Act, 1972
3. I hereby declare that I have no family within the meaning of clause (h) of section (2) of the said Act.
4. I hereby declare that
a. My father/mother/parents is/are not dependent on me.
b. My husband's father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the to the Controlling Authority in terms of the
proviso to clause (h) of section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Nominee(s)

Relationship Age of Proportion by

Name in full with full address of nominee(s) with the nominee which the gratuity
employee will be shared
1. P. Padma Latha Mother 52 50%

2. P. Uma Shankar Father 58 50%

3.

Statement
Name of employee in full. : Rohit Patnala
____________________
Gender : ____________________
Male
Religion : Hindu
____________________
Whether unmarried/married/widow/widower : ____________________
Unmarried
Department/Branch/Section where employed. : ____________________
Post held with Ticket or Serial No., if any : ____________________
Date of appointment. : ____________________
E-1301, Vajra’s
Permanent address. : ____________________
Jasmine County
Village- Financial District
Thana - Gachibowli Sub-division Nanakramguda Post Office - Gachibowli District RR
State Telangana

Place - Hyderabad
Date 09/07/2021 Signature/Thumb impression of the employee

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Declaration by witnesses

Nomination signed/thumb impressed before me

Name in full and full Signature of witnesses.

address of witnesses

1. P. Uma Shankar 1.

2. P. Padma Latha 2.

Place Hyderabad

Date 09/07/2021

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment

Employer's Reference No., if any

Date Signature of Employer/Office Authorized

Designation

Name and address of Establishment or rubber stamp thereof

Acknowledgement by the employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer

Date 09/07/2021 Signature of Employee

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