,fld&72

depkjh jkT; chek fuxe ESIC-72

Employees’ State Insurance Corporation

lok esaTo,
'kk[kk icU/kd The Branch Manager
'kk[kk dk;ky; Branch Office,
egkn;] Dear Sir,
ejk igpku i=k [kksx;k@[kjkc gksx;k g] vr% eSaigpku i=k dh vufyfi dsfy, ikFkuk djrk gwA
My Identity Card has been lost/defaced, I have therefore to request for a Duplicate Identity Card.
eSaigpku i=k dh vufyfi esa'kYd Lo:i ,d #i;k vnk djrk gw@eSaijkuk igpku i=k tek djrk gwA
I herewith deposit a sum of rupee 1/- only being the fee for the Duplicate Identity Card/I return herewith the Identity
Card Issued to me earlier.
pwfd [kjkc gvk igpku i=k 3 o"kZigysfn;k x;k Fkk e>sigpku i=k fu%'kyd inku fd;k tk,A
As the Card was issued more than 3 years ago, the Duplicate Identity Card may be issued to me free of Charge.
ejsoreku ikfjokfjd lnL;ksadk fooj.k fuEu idkj gA
The particulars of the present members of my family are furnished below :-
Øekd uke tUefrfFk chekfdr O;fDr lslc/k mldslkFk jg jgsgS@;k ugha
Sl. Name Date of Birth Relationship with Whether residing with
No. Insured person him/her or not
1.
2.
3.
4.
5.
6.
7.
8.

eSa,rn~}kjk ?kkf"kr djrk gwafd mi;qDr fooj.k ejs}kjk fn, x, gSavkj ejsvf/kdre fo'okl ,oatkudkjh dsvulkj lR;
gSavkj mu fooj.kksalsfeyrsgSatkseSusle;≤ ij fn, gSA
I hereby declare that the particulars above have been given by me and are true to the best of my knowledge and
belief and tally with those which I have furnished earlier from time to time.
eSa;g Hkh tkurk gwafd ;fn ejh ?kk"k.kk esadkbZfooj.k xyr ik;k rkseSadepkjh jkT; chek vf/kfu;e 1948 dh /kkjk 84 ds
vUrxr n.M dk Hkkxh gwxkA
Ñ-i-m- P.T.O.
I also understand that in case of any of the particulars in my declaration is found to be wrong, I shall be liable to
prosecution under section 84 of the E.S.I. Act, 1948
Hkonh; Yours faithfully

• lk{;kfdr Attested gLrk{kj ;k fu'kkuh vxBk Signature or thumb impression

ijk uke Full Name.......................................
chekd Ins No........................................
• lk{;kfdr vf/kdkjh dk uke o in
Name and Designation of the Attesting Authority
;g ikFkuk i=k oreku@fiNysfu;ktd ;k VªM ;fu;u dsv/;{k@e=kh vFkok 'kk[kk dk;ky; dsifjfpr O;fDr }kjk lk{;kfdr
gkuk pkfg,A
This application should be attested by the present employer or the last employer or the President or Secretary of a
Trade Union or a person known to the Branch Office.
fVIi.kh %& depkjh jkT; chek vf/kfu;e 1948 dh /kkjk (2) [k.M (ii) dsvulkj ifjokj dk vFkZchekfdr O;fDr ij vkfJr ifr ;k
iRuh vkj o/k rFkk nÙkd vYio;Ld cPpsvkj mldsvkfJr ekrk&firk lsgA
Note :- According to section 2 Clause (ii) of the Employees' State Insurance Act 1948 family means the spouse and
minor legitimate and adopted children dependant upon the insured person and his dependant parents.
¼'kk[kk dk;ky; grqTo be completed by Branch Office½
igpku fpUg ;fn fgrykHk Qkby ij vfdr u gks Identification mark if not given on the Benefit file
eSus ijkuk igpku i=k@ikfjokfjd i=k ikIr fd;kA I received Identity Card/Family Identity Card
issued earlier
1..................................................................................................................................................................................
2..................................................................................................................................................................................
........................................................................ 'kk[kk dk;ky; dh ekgj] udn jlhn l[;k................................................
iLrd l[;k..................... fnukd.................... }kjk ,d #i;k ¼doy ,d #i;k½............................ ikIr fd;A
Received Rupee 1/- (Rupee One only) vide Cash Receipt No.....................................................................................
Book No.................................................................. Dated................................................. Stamp of Branch Office.
1 #- dh 'kYd chekfdr O;fDr lsblfy, ughaikIr dh xbZD;ksfd cny fu%'kYd gkuk gA
Fee of Rupee 1/- has not been received from the insured person as replacement is to be done free of cost.

lfEefyr igpku i=k dh vufyfi ikIr dhA 'kk[kk icU/kd dsgLrk{kj Signature of Branch Manager
Duplicate Combined Identity Card received 'kk[kk dk;ky; Branch Office...............

chekfdr O;fDr dsgLrk{kj ;k fu'kkuh vxBk

• tksykxwu gksmlsdkV nsA Signature or thumb impression of the Insured person
• Delete whichever is not applicable chekd Ins. No.........................