FORM - 1 DECLARATION FORM

To be filled by employee after reading instructions overleaf. Two Postcard size Photographs to be attached with the form. This form is free of cost Employers Code No:

(A)

INSURED PERSONS PARTICULARS'

(b) EMPLOYERS PARTICULARS

Day Date of Appointment Month Year

1 Insurance No. 2 Name (in Block Letters) 3 Father's/Husband Name Day 4,

Date of Birth

P.KUMARAN
C.PARASURAMAN
Month Year 5. Marital status 6. Sex

6
11. Name & Address of the Employer

2010

1981

P M/U/ W P M/ F
12 a) -doa) In case of any previous employment please fill up the details as under:Previous Ins.No. Emplos.Code No.

7 Present Address

8 Permanent Address

No.4/934, J.J.Nagar Mogappair West Chennai

Pin Code Email ID : Branch Office 6 0 0 0 3 7 Pin Code

C) Name & Address of the Previous Employer

A.I.E.
Name

Dispensary

AMBATTUR
Relationship WIFE Address -DO-

(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.

K.VAISHNAVI

I hereby declare 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 to such change

Counter Signature by the employer with seal (D) FAMILY PARTICULARS OF INSURED PERSON
S.n
Date of Birth/Age as on date of filling form Relationship with the Employee Whether residing with him/her Say- Yes / No

Signature / T.I. of IP
If No. State place of Residence Town State

Name

1 K.VAISHNAVI 2 C.PARASURAMAN 3 P.PADMINI 4 5 6

20.03.1988 62 YEARS 54 YEARS

WIFE FATHER MOTHER

YES YES YES

ESI Corporation Temporary Identity Card (Valid for 3 months from the date of appointment) Name Ins.No. Branch office A.I.E. P.KUMARAN Date of Appointment Dispensary 6/9/2010 AMBATTUR
(Space for photograph)

51-00-057328-000-0606
Employers Code No. & Address

Validity Dated Signature / T.I. of I.P. Signature of B.M. with Seal

INSTRUCTIONS 1 2 Submission of Form-1 is governed by regulations 11 & 12 of ESI (General) Regulations, 1950 "Family" means all or any 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 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 physical or mental abnomality or injury and is wholy dependant on the earning of the I.P. so long as the infirmituy continues; (v) dependent parents (Please see Section 2 clause 11 of the ESI Act 1948 for details) Identity Card is Non-Transferable Loss of identity Card be reported to Employer / Branch Manager immediately Submission of false information attracts penal action under Section 84 of ESI Act, 1948 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 84 of the Act, against employer As an Insured person you and your dependant family members are entitled to full medical care from today itself. The other benefits in cash include (1) Sickness Benefit (2) Temporary Disable benefit (3) Permanent disablement benefit (4) Dependent benefit and (5) Materinity (incase of women employee) subject to fulfillment of contributory conditions. 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. :

3 4 5 6

Date of issue of T.I.C.

Name / No. of Disp. :

Whether reciprocal Medical arrangements involved, if yes, pleas indicate

Signature of Branch Manager

S.n

Name

Date of Birth/Age as on date of filling form

Relationship with the Employee

Whether residing with him/her Say- Yes / No

If No. State place of Residence Town State

1 K.VAISHNAVI 2 C.PARASURAMAN 3 4 5 6

20.03.1988 62 YEARS

WIFE FATHER

YES YES

0 0

0 0

EMPLOYEES' STATE INSURANCE CORPORATION

(To be submitted in Duplicate) REG. FORM - 3

RETURN OF DECLARATION FORMS

(Regulation 14) Name and Address of the Factory or Establishment

Employer's Code No : I am enclosing the Declaration Forms in respect of following employees. I hereby declare that each and every person, employed as an 'employee' within the meaning of Section 2 (9) of the Employees' State Insurance Act' 1948 on .in this factory or establishment and in receipt of a remuneration not exceeding Rs.15000/- (excluding remuneration for overtime work) per month have been included in this list (excepting those in respect of whom declaration forms have already been sent to the Corporation in the past). Date Signature.. Name in Block letters. Place.. Designation & Seal. Serial No. 1 1 2 3 4 Distinguishing No.with the Employer, if any 3 Insurance No. allotted by the Corporation (to be entered at the Local office) 5

Name of the employee 2

Father's Name 4

Enclosures: 1 Declaration forms in respect of the above named employees 2 Contribution sheet(s)

Signature

Signature.. Name in Block letters. Designation & Seal.