FORM - 1

DECLARATION FORM
To be filled by employee after reading instructions overleaf. Two Postcard size Photographs to be attached with the form. This form
is free of cost

Employers Code No:

(A) INSURED PERSONS PARTICULARS' (b) EMPLOYERS PARTICULARS
1 Insurance No. Day Month Year
Date of Appointment
2 Name (in Block Letters) P.KUMARAN 6 9 2010
11. Name & Address of the Employer
3 Father's/Husband Name C.PARASURAMAN
Day Month Year 5. Marital P
4, Date of Birth status M/U/ W
3 7 1981 6. Sex P M/ F
In case of any previous employment please fill up
7 Present Address 8 Permanent Address 12
the details as under:-

No.4/934, J.J.Nagar a) Previous Ins.No. -

Mogappair West -do- a) Emplos.Code No. -
C) Name & Address of the Previous Employer
Chennai

6 0 0 0 3 7
Pin Code Pin Code
-
Email ID :
Branch Office A.I.E. Dispensary AMBATTUR
(C) Details of Nominee u/s 71 of ESI Act 1948/Rule-56(2) of ESI (Central Rules 1950 for payment of cash benefit in the event of death.
Name Relationship Address
K.VAISHNAVI WIFE -DO-
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 to such change

Counter Signature by the employer with seal Signature / T.I. of IP

(D) FAMILY PARTICULARS OF INSURED PERSON
Date of Birth/Age as on Relationship with the Whether residing with If No. State place of Residence
S.n Name date of filling form Employee him/her Say- Yes / No Town State

1 K.VAISHNAVI 20.03.1988 WIFE YES

2 C.PARASURAMAN 62 YEARS FATHER YES
3 P.PADMINI 54 YEARS MOTHER YES
4
5
6

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

Name P.KUMARAN
Ins.No. Date of Appointment 6/9/2010
Branch office A.I.E. Dispensary AMBATTUR
51-00-057328-000-0606 (Space for photograph)

Employers Code No. & Address

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

1 Submission of Form-1 is governed by regulations 11 & 12 of ESI (General) Regulations, 1950

2 "Family" means all or any of the following relatives of an insured Person namely:-
(i) a spouse (ii) a minor legitimate or adopted child dependent upon the I.P., (iii) a child who is wholly
dependant on the earnings of the I.P. and who is (a) receiving education, till he or she attains the age
of 21 years (b) an unmarried daughter, (iv) a child who is infirm by reason of any physical or mental
abnomality or injury and is wholy dependant on the earning of the I.P. so long as the infirmituy continues;
(v) dependent parents (Please see Section 2 clause 11 of the ESI Act 1948 for details)

3 Identity Card is Non-Transferable

4 Loss of identity Card be reported to Employer / Branch Manager immediately

5 Submission of false information attracts penal action under Section 84 of ESI Act, 1948

6 This form duly filled in must reach the concerned Branch office within 10 days of appointment of an
Employee, Delay attracts penal action under Section 84 of the Act, against employer

7 As an Insured person you and your dependant family members are entitled to full medical care from today
itself. The other benefits in cash include (1) Sickness Benefit (2) Temporary Disable benefit (3) Permanent
disablement benefit (4) Dependent benefit and (5) Materinity (incase of women employee) subject to
fulfillment of contributory conditions.

8 For more details contact website of ESIC at www.esic.org.in or contact Regional office or Branch office

FOR BRANCH OFFICE USE ONLY

1 Date of allotment of Ins. No. :

2 Date of issue of T.I.C. :

3 Name / No. of Disp. :

4 Whether reciprocal Medical arrangements involved, if yes, pleas indicate

Signature of Branch Manager

Date of Birth/Age as on Relationship with the Whether residing with If No. State place of Residence
S.n Name date of filling form Employee him/her Say- Yes / No Town State

1 K.VAISHNAVI 20.03.1988 WIFE YES 0 0

2 C.PARASURAMAN 62 YEARS FATHER YES 0 0
3
4
5
6
 EMPLOYEES' STATE INSURANCE CORPORATION

(To be submitted in Duplicate) REG. FORM - 3

RETURN OF DECLARATION FORMS
(Regulation 14)

Name and Address of the Factory or Establishment

Employer's Code No :

I am enclosing the Declaration Forms in respect of following employees. I hereby declare that each and
every person, employed as an 'employee' within the meaning of Section 2 (9) of the Employees' State Insurance
Act' 1948 on ……………….in this factory or establishment and in receipt of a remuneration not exceeding
Rs.15000/- (excluding remuneration for overtime work) per month have been included in this list (excepting those
in respect of whom declaration forms have already been sent to the Corporation in the past).

Date ………………………… Signature………………………………………………………..

Name in Block letters………………………………………….

Place………………………..
Designation & Seal…………………………………………….

Distinguishing Insurance No. allotted by the

Serial
Name of the employee No.with the Father's Name Corporation (to be entered at the
No.
Employer, if any Local office)
1 2 3 4 5
1 -
2 -
3 -
4

Enclosures: Signature …………………………………………………

1 Declaration forms in respect of
the above named employees

2 Contribution sheet(s)
Signature………………………………………………………..

Name in Block letters………………………………………….

Designation & Seal…………………………………………….