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Form 1 ESI Declaration Form 20230111082958 cs70
Form 1 ESI Declaration Form 20230111082958 cs70
Form-1
Tobefilledbyemployeeafterreadinginstructionoverleaf.TwoPostcardSizephotographstobeattachedwiththe form. This form is free of
cost.
(b)Employer'sCodeNo.
(c)Name&AddressoftheEmployer
e-mailaddress
1.InsuranceNo.
2. Nameinblockletters VISHAL GOWDA G
3-Father's/ Gangaraju
Husband'sName
4-DateofBirth Day Month Marital M/U/W
Year Status
unmarri
ed
23 08 200 Sex M
0
7-PresentAddress 8-PermanentAddress
PinCode PinCode 5 6 0 0 7 9
BrachOffice Dispensary
(c)DetailsofNomineeu/s71ofESIAct1948/Rule-56(2)ofESI(Central)Rules,1950forpaymentofcashbenefitintheeventofdeath.
Ihereby
declarethattheparticularsgivenbymearecorrecttothebestofmyknowledgeandbelief.Iundertaketointimatethecorporationany
changes in the membership of my family within 15 days of such change.
CountersignaturebytheemployerSignature/T.I.ofIP.
Signaturewithseal
(D)FamilyParticularsofInsuredperson
SI. No. Name DateofBirth/Ageason Relationshipwithth Whether If'No'statePlaceof
dateoffillingform e residing Residence
Employee withhim/her.
ESICorporationTemporaryIdentityCard (Validfor3monthfromthedateofappointment)
Name
Ins.No. Dateofappointment
Employer'sCodeNo.&Address
Validity
(i) a spouse (ii) a minor legitimate or adopted child dependent upon the I.P.; (iii) a child who is wholly dependent on the
earningsoftheI.P.andwhois(a)receivingeducation,tillheorsheattainstheageof21years(b)anunmarried daughter.
(iv)achildwhoisinfirmbyreasonofanyphysicalormentalabnormalityorinjuryandiswhollydependentontheearnings
oftheI.P.solongastheinfirmitycontinues;(v)dependentparents(PleaseseeSection2clause11oftheESIAct1948for details
3- IdentityCardisNon-Transferable.
5- Submission of false informationattracts penal actionUnder Section 84of 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.
8- FormoredetailspleasecontactwebsiteofESICatwww.esic.org.in.orcontactRegionalOfficeorBranch Office.
ForBranchOfficeUseonly
1- DateofallotmentofIns.No.:
2- DateofIssueofT.I.C.:
3- Name/No.ofDispensary:
4- WhetherreciprocalMedicalarrangementsinvolved.ifyes,pleaseindicate:
Signature ofBranchManager