EMPLOYEES STATE INSURANCE CORPORATION

TEMPORARY IDENTITY CERTIFICATE

Insured Person : Kasyapa Satya Sairam Ivatury
Insurance No : 3304902333
Date of Registration :25/07/2011

YOUR REGISTRATION DETAILS

Employee Name :

Kasyapa Satya Sairam Ivatury

Type of Disability :

None

Name of Father / Husband:

I.P.S. Prasad

Date of Birth :

06/08/1987

Marital Status :

Unmarried

Gender :

Present Address :

SANTOSH NAGAR KATRAJ

PUNE,katraj,SWARGATE,
PUNE,Dist:Pune,Maharashtra,411046
None

Permanent Address

Dispensary / IMP :

Current Employer Details

1/296,D, Kovela,1st street paul pundi Nagar

housing board,Ext.
Tuticorin,Dist:Thoothukudi,Tamilnadu,628008

Previous Employer Details

Employer's Code No. :

33000420260001099

Employer's Code No. :

None

Sub Unit's Code No. :

None

Sub Unit's Code No. :

None

Date of Appointment :

01/09/2010

Previous Insurance No. :

None
None

Name of Employer :

QUALITY FUMIGATION SOLUTION

Name of Employer :

Address of Employer :

12/13, PATIL PLAZA,MITRAMANDAL

CHOWK,PUNE,Dist:PuneMaharashtra41100
9

Address of Employer :

Family Details:
Name

Relationship with the Employe

father
Parvatheeswara Satya PrasadDependant
Ivaturi

Date of Birth

07/04/1955

Whether Residing with I

None

State

Andhra Pradesh

District

Vijayawada

Nominee Details:
Name of Nominee

Relationship with IP

Parvatheeswara Satya Prasad Ivaaturi

Dependant father

Percentage

Address of Nominee

59A-5-3/11, P.No: 66,,3rd Lane, new P&T Colony,,Near Stella College, Benz Circle,,Andhra P

Documents Uploaded:
none

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
09/08/2011 , in the Below Branch Office : BO - BIBVEWADI,689-690 Panchdeep Bhavan, Bibewadi, Pune,0 or any nearest ESIC

Bio-metric Camp Locations.

Signature / LTI of Registered Employee / IP :

Mobile Number :

Affix Your Family Photograph Here.(Attested and Stamped by Employer / ESIC Official)

0123456789

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