Form-1 - Declaration Form (India) printable pdf download

DECLARATION FORM

Form-1

?kks " k.kk i=k

QkeZ & 1@

?kks " k.kk i=k deZ p kjh }kjk Hkjk tk,xkA QkeZ ds LkkFk iks L VdkMZ vkdkj ds nks Qks V ks x z k Q Hkh yxk, tkus pkfg,A QkeZ Hkjus ls igys

ihB i` " B ij nh xbZ fgnk;rks a dks Hkyh&Hkka f r i<+ ys u k pkfg,A ;g QkeZ fu%'kq Y d gS A

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.

¼d½

chekÑr O;fDr ds fooj.k

¼[k½

fu;ks t d ds fooj.k

(A)

INSURED PERSON'S PARTICULARS

(B)

EMPLOYER'S PARTICULARS

9- fu;ks t d dh dw V la [ ;k

@Insurance No.

1- chek la [ ;k

Employer's Code No.

2- uke ¼Li"V v{kjks es a ½

10- fu;q f Dr dh rkjh[k

fnu

eghuk

o"kZ

Name in block letters

Date of Appointment

Day

Month

Year

3- firk@ifr dk uke

Father's/Husband's Name

Name & Address of the Employer

11- fu;ks t d dk uke vkS j irk@

__________________________________________________

4- tUe dh frfFk

fnu eghuk o"kZ

5- oS o kfgd fookfgr@

__________________________________________________

Date of Birth

Day Month Year

iz k fLFkfr

vfookfgr

__________________________________________________

Marital

fo/kok

Status

M/U/W

12- ;fn igys fu;ks t u es a jgs gS a rks Ñi;k fuEufyf[kr C;kS j s nhft,

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

Sex

/M.F.

iq - e-

fya x

¼d½ fiNyh chek la [ ;k

Present Address

Permanent Address

7- orZ e ku irk@

8- LFkk;h irk@

(a) Previous Ins. No.

______________________

¼[k½ fu;ks t d dw V la [ ;k

______________________

(b) Employer's Code No.

fiu dks M

Pin Code

¼x½ fu;ks t d dk uke o irk

Vs y hQks u uEcj@bZ & es y irk@

'kk[kk dk;kZ y ;

vkS " k/kky;

e-mail address

Vs y hQks u uEcj@bZ & es y irk@

Brach Office

Dispensary

¼d½ e` R ;q dh fLFkfr es a udn fgrykHk ds Hkq x rku ds fy, d-jk-ch- vf/kfu;e] 1948 dh /kkjk 71@d-jk-ch- ¼ds U nz h ;½ fu;e] 1950 ds fu;e 56¼2½ ds va r xZ r ukfer ds C;kS j s A

(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

uke@

ukrs n kjh@

irk@

eS a ,rn~ } kjk ?kks " k.kk djrk@djrh gw a fd es j s }kjk iz L rq r fd, x, fooj.k es j h tkudkjh vkS j fo'okl ds vuq l kj lgh gS A eS a vius ifjokj ds lnL;ks a es a gq , ifjorZ u dh lw p uk

15 fnu ds Hkhrj iz L rq r djus dk opu Hkh ns r k gw a @ ns r h gw a A

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.

fu;ks t d ds iz f rgLrk{kj

chekÑr O;fDr ds gLrk{kj@va x w B k fu'kku

Counter signature by the employer

Signature /T.I.of IP.

lhy lfgr gLrk{kj

Signature with seal

¼?k½ chekÑr O;fDr ds ifjtuks a dk fooj.k

(D) Family Particulars of Insured person

Ø-la -

uke

QkeZ Hkjus dh rkjh[k

deZ p kjh ds lkFk ukrs n kjh

D;k muds lkFk jg

;fn ugha rks vkokl

SI. No.

Name

Relationship with the

dks vk;q @ tUe&rkjh[k

jgs gS a \ crk,a

dk LFkku n'kkZ , a

Date of Birth/Age as on

Employee

Whether residing

If' No' state Place of

date of filling form

with him/her.

Residence

Yes

Town

State

gk¡ @

ugha @

dLck@

jkT;@

d-jk-ch- fuxe vLFkk;h igpku i=k

¼fu;q f Dr dh rkjh[k ls 3 eghus rd oS / k½

ESI Corporation Temporary Identity Card

(Valid for 3 month from the date of appointment)

Name

uke@

Ins. No.

Date of appointment

chek la [ ;k@

fu;q f Dr dh rkjh[k@

Qks V ks ds fy, LFkku

'kk[kk dk;kZ y ;

vkS " k/kky;

(Space for photograph)

Branch Office

Dispensary

fu;ks t d dh dw V la [ ;k o irk

Employer's Code No. & Address

oS / krk

Validity

rkjh[k

chekÑr O;fDr ds gLrk{kj@va x w B s dk fu'kku

lhy lfgr 'kk[kk iz c a / kd ds gLrk{kj

Dated

Signature/T.I. of I.P.

Signature of B.M. with seal

Form-1 - Declaration Form (India)

Related Articles

Related forms

Related Categories