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    Esic Registeration Form

    Uploaded by

    sonainter
    This document is a temporary identity certificate issued by the Employees State Insurance Corporation to an insured person. It provides registration details such as the insured person's name, father/husband's name, date of birth, gender, addresses, employer details, family details, and nominee details. The insured person is requested to visit the branch office by a given date to get their biometric and photo captured in order to obtain a permanent ID card. The certificate must be kept for future reference and medical benefits until the biometric card is received.

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    Esic Registeration Form

    Uploaded by

    sonainter
    7 views1 page
    This document is a temporary identity certificate issued by the Employees State Insurance Corporation to an insured person. It provides registration details such as the insured person's name, father/husband's name, date of birth, gender, addresses, employer details, family details, and nominee details. The insured person is requested to visit the branch office by a given date to get their biometric and photo captured in order to obtain a permanent ID card. The certificate must be kept for future reference and medical benefits until the biometric card is received.

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    Original Title

    ESIC REGISTERATION FORM

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    This document is a temporary identity certificate issued by the Employees State Insurance Corporation to an insured person. It provides registration details such as the insured person's name, father/husband's name, date of birth, gender, addresses, employer details, family details, and nominee details. The insured person is requested to visit the branch office by a given date to get their biometric and photo captured in order to obtain a permanent ID card. The certificate must be kept for future reference and medical benefits until the biometric card is received.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    7 views1 page

    Esic Registeration Form

    Uploaded by

    sonainter
    This document is a temporary identity certificate issued by the Employees State Insurance Corporation to an insured person. It provides registration details such as the insured person's name, father/husband's name, date of birth, gender, addresses, employer details, family details, and nominee details. The insured person is requested to visit the branch office by a given date to get their biometric and photo captured in order to obtain a permanent ID card. The certificate must be kept for future reference and medical benefits until the biometric card is received.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 1

    EMPLOYEES STATE INSURANCE CORPORATION

    TEMPORARY IDENTITY CERTIFICATE


    Insured Person : . Insurance No : . Date of Registration :.

    YOUR REGISTRATION DETAILS


    Employee Name : Name of Father / Husband: Marital Status : Present Address :

    . . . . . .

    Type of Disability : Date of Birth : Gender : Permanent Address :

    . .

    Dispensary / IMP : Current Employer Details Employer's Code No. : Sub Unit's Code No. : Date of Appointment : Name of Employer : Address of Employer :

    Previous Employer Details

    17000600290000911 None . Chief Executive Officer Society for Promotion of IT in Chandigarh, Chandigarh, Chandigarh, 160012
    Relationship with the Employe . Date of Birth

    Employer's Code No. : Sub Unit's Code No. : Previous Insurance No. : Name of Employer : Address of Employer :

    None. .None . . .

    Family Details:
    Name Whether Residing with I State District

    Nominee Details:
    Name of Nominee . Relationship with IP Percentage Address of Nominee

    Documents Uploaded: Please Verify the Above Particulars. Please Notify Your Employer or in the Branch Office Address Below Incase of Any Information Found Incorrect.
    To get permanent ID card, employee is requested to visit the following branch office to get biometric & photo captured by this date 20/07/2011 , in the Below Branch Office : BO- Chandigarh BO- Chandigarh Branch Manager, ESI Corporation, ESI Dispensary Complex, Sector 29, Chandigarh-160029 or any nearest ESIC Bio-metric Camp Locations.
    Signature / LTI of Registered Employee / IP : Affix Your Family Photograph Here.(Attested and Stamped by Employer / ESIC Official)

    Mobile Number :
    NOTE:
    1. Please Keep this Printout for Future Reference and Bring this Along with Your Photo ID Card for All Your Claim Benefits and Medical Benefits . 2. This Copy Should be Retained with You until the Biometric Card is Dispatched . 3. Employer to please affix employee and his family photo here and attest with official stamp across . Signature / Stamp of ESIC Officer / Employer

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