EMPLOYEES STATEINSURANCE CORPORATION

FORM-1
o De tied in by the employee after reading instructions overleaf. Two Postcard Size photographs are to be

attached with this form. This form is free of cost.

(A) INSURED PERSON'S PARTICULARS (b) EMPLOYER'S PARTICULARS

1.Insurance No. Employer's Code
2Name (in blockSOMBATHINI SURA
letters) TEJA 10. Date of Day Month Year
Father's/Husband's SoMBATHTNT
Name VIJAA KUMW me RAddress of the Employer
Date of Birth D Marital M/U/W
Status

66 |0K 1914 6.Sex M/F

Present Address 8.Permanent Address 12. In case of any previous employment
34-2K 634-H-2 please fill up the details as under:
SURyA NAGAR,SBT SLIRYA NAGAR,SBE a) Previous Ins.No.

BANK BALKSIDE BANKBAckSID b) Emplr's Code No.

RLy KoDUR C) Name & address of the Employer
Pin Code 5 L 1 0 . ******* Pin Code.5\6l21.**

e-mail address e-mail address

SuryateiaA1@gmai
Bratch Office
yatejaksA gmeul ce
GmDispehsaryy e-mail address

(C) Details of Nominee u/s 71 of ESI Act 1948/Rule 56(2) of ESI (Central) Rules, 1950 for
payment of cash benefitin the event of death.
Name RelationshipAddress
vETAYA KUMAR.3FATHER7/34--25 LKYa NAgAE,RLy koDUR.
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 of such
change
Counter signature by the employer
Signature/T.I.of IP

Signature with Seal

(D) FAMILY PARTICULARS OF INSURED PERSON

Name Date of Birth/ Age Relationship with Whether If'No', state place of
as on date of the Employee residing with Residence
filling formn him/her?
Yes No Town State
LATHA aOK|16| yoKER
viAYAkUMAR 4SI4a% FATtHER

- ---- -. -----****-*-**-**************************************************************************************************************** . * .

ESI Corporation (Valid for 3 months from the date of appointment)

Temporary ldentity Card

Name

Ins.No. Date of appointment

Space lor photograph

Branch Office Dispensary

Employers Code No.&

Address

Validity

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

1. Submission of Form-l i5 governed by regulations 11 & 12 of ESI (General) Regulations, 1950.
 "Family" means all or any of the following relatives of an Insured Person namely

adopted child dependant upon the I.P;(ii) a chiid who is wholly

A spouse (li) a minor legitimate or
(0)
education, till he or she attains the age of
on the earnings of the I.P. and who is (a)receiving
dependant
of physical or mental
married daughter, (iv) a child who is infirm by reason any
21 years (b}an un

on the earnings of the I.P. so long as the infirmity

abnormity or injury and is wholly dependant
Section 2 clause 11 of the ESI Act 1948 for details)
continues; (v) dependant parents (Please see

Identity Card is Non-transferable

to Employer/Branch Manager immediately.

4. Loss of Identity Card be reported
1948.
attracts penal action under Section 84 of ESI Act,
5. Submission of false information
concerned Branch office within 10 days
of appointment of an
This form duly filled in must reach the
6.
action under Section 85 of the Act, against
employer.
Employee. Delay attracts penal
The
Insured person you and your dependent family
members are entitled to full medical care.
As an
Permanent
benefit (3)
incash include (1) sickness Benefit (2)
Temporary Disablement
other benefits
Benefit (incase of women employees
disablement Benefit (4) Dependents benefit and (5) Maternity
conditions.
subject to fulfiliment of contributory
contact
at Www.esic.nic in or www.esickar.gov.in
8. For more details Please Visit website of ESIC

Regional office or Branch Office.

FORBRANCH OFFICE USE ONLY

1. Date of Allotment of Ins. No.

2. Date of issue of TIC :

3 Name/ No. of Disp

indicate
4 Whether reciprocal Medical arrangements
involved?
If yes, please

Signature of Branch Manager

Relationship Whether If 'No', state place

Name Date of Birth/Age
SI. with the residing with of Residence
as on date of
No him/her?
filling form Employeees State
Yes No Town