ESI NOMINATION FORM

EMPLOYEE NAME:

ESIC NO

NAME OF FATHER / HUSBAND

DATE OF BIRTH:

DATE OF JOINING

MARITAL STATUS:

GENDER:

ADHAAR No. / PAN NO./

ELECTION CARD NO.-

MOBILE No.

DISPENSARY NAME :

PRESENT ADDRESS:

Pin code:- Mobile No.

Email ID:

PERMANENT ADDRESS:

Pin code:- Mobile No.

Email ID:
NAME OF THE NOMINEE

RELATION WITH EMPLOYEE

ADDRESS OF NOMINEE

Pin code:-

ADHAAR No. of the Nominee

Mobile. No.

FAMILY DETAILS:

RELATIONSHIP WHETHER
NAME: DATE OF BIRTH
WITH EMPLOYEES RESIDING WITH

YES / NO
(if no mention place
of residence)

BANK DETAILS:
NAME OF
BANK ACCOUNT NO. TYPE OF ACCOUNT NAME OF THE BANK
BRANCH
OMINATION FORM

Mobile No.

Mobile No.
 AADHAAR No.

MICR CODE
OF THE IFSC CODE OF THE BRANCH
BRANCH