DECLARATION FORM FORM-1
To be filled by employee after reading instruction overleaf. Two Postcard Size photograph to be attached with the
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 in block letters 10.Date of Appointment Day Month Year
1 2017
3.Father's/Husband's Name
11.Name & Address of the Employer
4.Date of Birth Day Month Year 5.Marital M/S/W/D
Status
1 12 2017 6.Sex
7.Present Address 8.Permanent Address 12.In case of any previous employment please fill up the details
as under.
, , , ,
(a) Previous Ins. No.
(b) Employer's Code No.
(c) Name & Address of the Employer
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 decalare 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
SI NO NAME DATE OF Relationship with th Whether residing wit If' No' state Place
BIRTH e Employee h him/her. of Residence
YES NO Town State
ESI Corporation Temporary Identity Card (Valid for 3 month from the date of appointment)
Name
Ins. No. Date of appointment
(Space for photograph)
Branch Office Dispensary
Employer's Code No. & Address
INSTRUCTIONS
1.Submission of Form-I is governed by regulation 11 & 12 of ESI (General) Regulations, 1950
2.'Family' means all or any of the following relatives of an Insured Persion 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 unmarried daughter;
(iv) a child who is infirm by reason of any physcial or mental abnormality 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.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 dependant family membes are entitled to full medical care. The other benefits in cash
include (1) Sickness Benefit (2) Temporary Disablement benefit (3) Permanent disablement Benefit (4) Dependants benefit
and (5) Maternity Benefit (in case of woman employees) subject of fulfillment of contributory cnditions.
8.For more details please contact website of ESIC at www. esic.org. in. or contact Regional Office or Branch Office.
For Branch Office Use only
1.Date of allotment of Ins. No. :
2.Date of Issue of T.I.C. :
3.Name /No. of Dispensary :
4.Whether reciprocal Medical arrangements involved. if yes, please indicate :
Signature of Branch Manager
SI NO NAME DATE OF Relationship with th Whether residing wit If' No' state Place
BIRTH e Employee h him/her. of Residence
YES NO Town State
