DECLARATION FORM FORM-1
Employer's Code
__________________________________________________
No.
(A) Insured Person's Particulars (B) Employer's Particulars
1.Insurance No. Day Month Year
2.Name 10. Date of
(in block RAMKESH MEENA Appointment
capital)
3.Father's/ 11. Name & Address of the employer
Husband's PHAILEE RAM MEENA
Name
DD MM YY 5.Martial
Unmarried
4.Date of Birth Status
10 11 1995 6. Sex Male
7. Present Address 8. Permanent Address
Makan number 72, maruti Village bandri post hapawas 12. In case of any previous employment
nagar in Bairwa colony near tehsil paparda, district dausa please fillup the details as under:-
Sanganer thana jaipur Rajasthan 303506 Previous Ins. No.
Mobile 9602670678 Emplrs. Code No.
11. Name & Address of the employer
Branch office: Dispensary :
(C) Details of the nominee u/s 71 of ESI Act1948 / Rule 56(2) of ESI (Central) Rules 1950 for payment of cash
benefit in the event of death
Name of the Nominee Relationship with insured
Address
person
Village bandri post hapawas tehsil paparda,
PHAILEE RAM MEENA Father
district dausa Rajasthan 303506
I hereby declare that the above particulars have been given by me and are correct to the best of my knowledge
and I belief. I also under take to intimate to the corporation any change in the membership of my family within 15
days of
such change having occured.
Counter Signature of the Employer
Signature with Seal Signature / T.I. of I P
(D) FAMILY PARTICULARS OF INSURED PERSON
Relationship Whether residing
Sl. If No, State place of
Name Date of Birth with with
No. Residence
insured person him/her or not
YES / NO TOWN STATE
1 NOT Village bandri post
hapawas tehsil
PHAILEE RAM MEENA Father paparda, district
dausa Rajasthan
303506
2 NOT Village bandri post
hapawas tehsil
NANGEE DEVI Mother paparda, district
dausa Rajasthan
303506
3
4
5
6
7
ESI CORPORATION
Valid for 3 months from the date of
Temporary Identity Card appointment
Name RAMKESH MEENA
Ins. No Date of Entry Affix Photo
Father's/
PHAILEE RAM 10-11-
Husband's Date of Birth
MEENA 1995
Name
Branch Office Dispensary
Name,
Address &
Code No. of
the employer
Validity Dated Signature / T.I. of I P Signature of B.M. with Seal
INSTRUCTIONS
1 Submission of Form 1 is governed by regulations 11 & 12 of ESI (General) Regulations, 1950
2*Family* means all or any one of the following relatives of an insured person namely:-
(i) a 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 of 21 years (b)
an un married daughter; (iv) a child who is infirm by reason of any physical or mental abnormality or injury
and is wholly dependent on the earnings of the I.P. so long as the infirmly continues; (v) dependent
Parents
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 dully 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 the employer
7 As an insured person you and your dependent family members are entitled to full medical benefit from
today itself. 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 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 Disp. :
4. Whether reciprocal Medical arrangements involved, if yes, Please
indicate
Signature of Branch Manager
Sl. Relationshipwith Whetherresidingwith IfNo,Stateplaceof
Name DateofBirth
No. insuredperson him/herornot Residence
YES/NO TOWN STATE
1
