~ 'q':t DECLARATION FORM tfiTlf-1/Form-1

~ l:J3f ~ &RT 'lffi ~ 1l:fiTlt <f; Wf ~ 311m <f; GT ~ ~ '{iflIl1:( ;;rA ~ I tfiTlf ~ ~ ~

1fto ~ 1R ~ ~ ~ q;f ~-'llifu ~ -w.rr _ I~ l:fiTlt f.r:~ ~ I

To be filled by employee after reading instruction overleaf. Two Postcard Size phtographs to be attached with the
form. This form is free of cost.

(CIl) ~ ~ <f; ~ ("&:) ~<f;~

(A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS

ce
I fiRq;)s
Month
5.~Yea
eN
1. ojllrrlJtRr
~~
M1UIW
fcltrcrr
~I
I
~PrJM.F
tffiqr/lnsurance Dayft.f
No.
8. ~
~~-1ffi1M1
~ IffiT/Permanent
Dispensary
Pin Code I
Address 9. ~ctT~mr
Status
Marital Name inC/iT
block
Father's/Husband's lettersName Employer's Code No.,
~-1ffi 1M1 6.f~i7flSex 3 .litffi/~
4.;;pf <tT ft'lftr
2.1l'J (~
1l'J
3lmT if)
10. ~ ctT <l1t't& It.:r 'ItAT cr<t

Date of Appointment Day Month Year

11.~ ~ 'Il"f 3itt 'RlT/Name & Address of the Employer

12. ~
In case of any previous employment please fill up the details as under.

(~) ~ oi\'!T mr
(a) Previous Ins. No.

(~)~~mr
(b) Employer's Code No.

(If) ~ 'liT 'Il"f q 'RlT

(c) Name & Address of the Employer

~ ~~-1ffi lffiT/e-maii address

(~) 'ffi ctT ~ ~ 'l'IiG ~ <f; 'TJCIFf <f; ~ ~.n:~.~, 1948 ctT am 7I/~.n.~. (~) f.I<l1f, 1950 <f; f.I<l1f 56(2) <f; ~ 'lTfi:la <f; 01ffi: I
(c) Details of Nominee uls 71 of ESI Act 1948/Rule-56(2) of ESI (Central) Rules, 1950 for payment of cash benefit in the event of death.

'Il"f/Name ~/Relationship IffiT/Address

~15lt.:r
~ <f; 1fuR~
~ <t«lfl<lm'fi t~
'6f.t 'liT qq.f -qr'1ft&m
tIT ~~ ~tl ~ ~ 1ffi ~ 3itt ~ <f; ~ '6tt ~ I ~ 3l1l't 'l'fim <f; ~ ~ ~ '!ftcl<R ctT ~
I hereby decalare that the particulars given by me are correct to the best of my knowledge and belief. I undertakEl to intimate the corporation any
changes in the memberShip of my family within 15 days of such change.

~<f;~ ~ ~ <f; mJmI3i¥r f.mR

Counter signature by the employer Signature fT.1.of IP.

~"mRR
Signature w~h seal
(ti) ~ ~ <f; qft;Rf ~ ~

(D) Family Particulars of Insured person

lIi."H.
~/State
Name
'Il"f 'liT'f
'ltf/No
~/Town Whether
q;) 'lffi'
If'~<f;-am~
No'
~'ltfm~ ~~~
ctT
~;;iR-mfug
Relationship ~~?
CfllT mfug
state
Residence iR'f;Place ~of
-am the
iI<mt
residing
Employee
with w~h him/her.

~.n.o\T. f.rTq 3Wll<ft ~ 'l'f ~ctTorfug~ 3~<f1Ii~)

ESI Corporation Temporary Ident~y Card (Valid for 3 montl1 from the date of appointment)

'Il'f/Name ~
Dispensary
~ ctT ~Date of appointment
Employer's Code No. & Address
ilT'lT ti&wlns. No.

1!iR.)<f; ~~
(Space for photograph)

-
Validity
tlTOO ~ ~ <f; mJmI~ 'liT f.Im ~~~W~<f;~
Dated Signature/T.I. of I.P. Signature of B.M. with seal
 ~~
INSTRUCTIONS

1. 1Oflf-1 CIiT M Cfl:U:.ft. (mtmUr) ~, 1950 <fi-~ 11 cr 12 <fi-~ ~ fcl;l:rr ~ ~ I

Submission of Form-I is governed by regulation 11 & 12 of ESI (General) Regulations, 1950

2. "~"~~~~<fi-~""Iffflf@C1\'1'lfi~~~~~:-
~:- (1) ~ (2) ~ ~ 'tf{ ~ ~ wfuf <iT~ ~ ~ <rfW.Ii, (3) ~ <rfW.Ii;;TI~ ~
<fi-~ "CIT~: ~ ~ (1m ;;TI (Cfl) fum ~ Cfl\ m ~,~ 21 qt et't ~ "IWa Cfl\ ~ oq; ("&") CI>1t~ ~,
(4) ~ <rfW.Ii;;TI~ mftltco 3llro ~ ~N{1lql"llC11<iT~ <fi-cmur ~ ~ om ~IIt:1\'i1illC11
~"dCfl ~ ~
<fi-~"CIT~: ~ i, (5) ~ lffilT-flrnr, (ozilt ~ Cfl.~.<lT.~, 1948 et't tmT 2 <f; m 11 <01~) I

"Family" means all or any of the following relatives of an Insured Person namely:-

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

3 ~-~ 3ti?f('lI"fl<u~q ~ I
Identity Card is Non-Transferable.

4. ~-~ <f; Elf ~ et't ~ tl ~/mm ~ <01 ~ ~ fcl;l:rr ~ I

Loss of Identity Card be reported to Employer/Branch Manager immediately.

5. ~ "IICIiRet't 1f\'iIO ~ ~ et't ~ tl Cfl.~.<lT. ~, 1948 et't tmT-84 <f; mm ~ ~ et't \;iT ~ ~ I
Submission of false information attracts penal action Under Section 84 of ESI Act. 1948.

6. ~ ~ et't ~ tl 'lWIT-'\."fifa"
'lffi 83fT ~ 10flf ~ <f; G\'f ~ <f; 1fuR ~ mm ~ if ~ tT ~ f<t;m
;;rr;:rr ~ I~ et't ~ if ~ <fi-~ tmT-85 <fi-mm • ~ et't \;iT ~ % I
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. ~ ~ ~ <f; "fffi.3fTq cr ~ 1:Jf{cm" <fi-~ ~ ~ "IWa Cfl\ wfiit I ~ 'lcR ~~, (1) oft1:Irtt
~ (2) ~ ~ ~ (3) ~ ~ ~ (4) ~ fm!N (5) • fm!N (~Cfi*rrtT <f;~) I
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. 3tftrco~<fi-~~f.l1Jlr<fi-~<o1~<iT~~<iT~~~~~1
For more details please contact website of ESIC at www.esic.org. in. or contact Regional Office or Branch Office.

~rnfT~1{~~
For Branch Office Use only

1. oft1rr ~ ~ et't mfug :

Date of allotment of Ins. No. : _

2. ~ 1Wm"f ~ iiITfr coR c6t ~ :

Date of Issue of T.LC. : _

3. ~ CIiT"fTl1~ :
Name /No. of Dispensary: _

4. qm~~~~~?~~,m~~.:
Whether reciprocal Medical arrangements involved. if yes, please indicate:

mm~<fi-~
Signature of Branch Manager

",.tt. Name
~te 'lJll'lil'f'I«<tt~
;OO/No
C6OO/Town ~«;~~
~~~
Whether
q,1 Residence
If'Relationship
No, state
~arrgNfrif~ffi Place
Employee
~~?~
residing
'f<lT~~~
"ftf, of
with the
3fICIffi with him/her.