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  • Form 1 ESI Declaration Form 20230111082958 cs70

    Uploaded by

    MOHIT Kumar
    58 views3 pages
    This document is a declaration form for an employee to fill out after reading the instructions on the back. It collects personal details of the insured employee (Name, Father's Name, Date of Birth, Address, etc.) and employer details (Employer's Code, Address, Date of Appointment). It also collects details of the employee's nominee under section 71 of the ESI Act for payment of cash benefits in the event of death. The employee declares the details provided are correct. The form is to be submitted to the concerned Branch Office within 10 days of appointment. It provides entitlement to full medical care for the employee and dependent family members through the ESIC scheme.

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    Original Title

    Form-1-ESI-Declaration-Form-20230111082958-cs70

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    This document is a declaration form for an employee to fill out after reading the instructions on the back. It collects personal details of the insured employee (Name, Father's Name, Date of Birth, Address, etc.) and employer details (Employer's Code, Address, Date of Appointment). It also collects details of the employee's nominee under section 71 of the ESI Act for payment of cash benefits in the event of death. The employee declares the details provided are correct. The form is to be submitted to the concerned Branch Office within 10 days of appointment. It provides entitlement to full medical care for the employee and dependent family members through the ESIC scheme.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    58 views3 pages

    Form 1 ESI Declaration Form 20230111082958 cs70

    Uploaded by

    MOHIT Kumar
    This document is a declaration form for an employee to fill out after reading the instructions on the back. It collects personal details of the insured employee (Name, Father's Name, Date of Birth, Address, etc.) and employer details (Employer's Code, Address, Date of Appointment). It also collects details of the employee's nominee under section 71 of the ESI Act for payment of cash benefits in the event of death. The employee declares the details provided are correct. The form is to be submitted to the concerned Branch Office within 10 days of appointment. It provides entitlement to full medical care for the employee and dependent family members through the ESIC scheme.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    DECLARATIONFORM

    Form-1
    Tobefilledbyemployeeafterreadinginstructionoverleaf.TwoPostcardSizephotographstobeattachedwiththe form. This form is free of
    cost.

    (A) INSUREDPERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS


    9-Employer'sCodeNo.

    10- Day Month


    DateofAppointment Year
    12 01 2023

    No 35 4th crosss 1st main BDA layout pattegarapalya basaveshwara


    nagar
    12-
    Incaseofanypreviousemploymentpleasefillupthedetailsasund
    er.
    (a)PreviousIns. No.

    (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.

    Name Relationship Address


    Renuka Mother No 35 4th crosss 1st main BDA layout pattegarapalya
    basaveshwara nagar

    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.

    1 Renuka K 16/06/1981 Mother Yes Town State


    2

    ESICorporationTemporaryIdentityCard (Validfor3monthfromthedateofappointment)

    Name
    Ins.No. Dateofappointment

    BranchOffice Dispensary (Spaceforphotograp


    h)

    Employer'sCodeNo.&Address

    Validity

    Dated 12/02/2023 Signature/T.I.ofI.P. SignatureofB.M.with seal


    INSTRUCTIONS

    1- SubmissionofForm-Iisgovernedbyregulation 11&12ofESI(General)Regulations, 1950

    2- "Family" means all orany of thefollowing relatives ofan Insured Personnamely:-

    (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.

    4- Lossof IdentityCard bereported toEmployer/Branch Managerimmediately.

    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.

    7- Asaninsuredpersonyouandyour dependentfamily membersareentitledtofullmedicalcare.Theotherbenefitsincash include


    (1) Sickness Benefit (2) Temporary Disablement benefit (3) Permanent disablement Benefit (4) Dependents benefitand
    (5) Maternity Benefit (in case of womanemployees) subject of fulfillment of contributory conditions.

    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

    DateofBirth/Ageason Relationshipwithth Whether If'No,statePlaceof


    SI.No. Nam dateoffillingform e residing Residence
    e Employee withhim/
    her.
    Yes No Town State

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