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    New ESIC DECLARATION FORM

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    This document is an ESIC (Employee's State Insurance Corporation) declaration form for an insured person to provide details of themselves and their nominee for cash benefits. It requests information such as the insured person's name, ESIC number, father/husband's name, date of birth, address, family members' names and dates of birth, and nominee's name, relationship, date of birth, address and Aadhar number. The form is used to collect necessary information for the insured person's ESIC records and to designate a nominee who would receive cash benefits in the event of the insured person's death.

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    New ESIC DECLARATION FORM

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    PC Creation
    13 views1 page
    This document is an ESIC (Employee's State Insurance Corporation) declaration form for an insured person to provide details of themselves and their nominee for cash benefits. It requests information such as the insured person's name, ESIC number, father/husband's name, date of birth, address, family members' names and dates of birth, and nominee's name, relationship, date of birth, address and Aadhar number. The form is used to collect necessary information for the insured person's ESIC records and to designate a nominee who would receive cash benefits in the event of the insured person's death.

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    New_ESIC_DECLARATION_FORM.xlsx

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    This document is an ESIC (Employee's State Insurance Corporation) declaration form for an insured person to provide details of themselves and their nominee for cash benefits. It requests information such as the insured person's name, ESIC number, father/husband's name, date of birth, address, family members' names and dates of birth, and nominee's name, relationship, date of birth, address and Aadhar number. The form is used to collect necessary information for the insured person's ESIC records and to designate a nominee who would receive cash benefits in the event of the insured person's death.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    13 views1 page

    New ESIC DECLARATION FORM

    Uploaded by

    PC Creation
    This document is an ESIC (Employee's State Insurance Corporation) declaration form for an insured person to provide details of themselves and their nominee for cash benefits. It requests information such as the insured person's name, ESIC number, father/husband's name, date of birth, address, family members' names and dates of birth, and nominee's name, relationship, date of birth, address and Aadhar number. The form is used to collect necessary information for the insured person's ESIC records and to designate a nominee who would receive cash benefits in the event of the insured person's death.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
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    ESIC DECLARATION FORM

    Employees code
    Branch office

    B. Details of nominee u/s 71 of ESIC Act , 1948/ Rul 56(2) of ESI (Central) Rules, 1950 for payment of cash benefit in
    A. Insured Person's Particulars the event of death

    1. ESIC NO of previous employer if any 11. Full name of the Nominee

    2. Name of the Employee 12. Relationship with members

    3. Father's / Husb+C39and's name 13. (a) Present Address 13. (b) Permenant Address

    MM DD YYYY
    4. Date of Birth
    PIN No - PIN No -
    5. Gender / Sex 8. Aadhar No.
    MM DD YYYY
    6. Marital Status 9. Mobile no & Email ID. 14. Date of Birth of nominee

    7. (a) Present Address 7. (b) Permenant Address


    15. Aadhar No. of nominee

    PIN No - PIN No -

    C. Family particulars of Insurnced perosn

    Whether residing with


    Date of birth him/her
    Father's / Husband's If no, state place of
    Name of the family member name DD MM YYYY Relationship with members Aadhar no. Yes No residence

    Signature of the Employee


    Note : All columns are mandatory

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