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  • Declaration Form - Employees' State Insurance Corporation (ESIC)

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    Yogesh Ramesh Parmar declares insurance details including personal information like name, date of birth, address, and family details. He provides his father Ramesh's name, declares his marital status as single, and notes his permanent and present addresses. Details of his employer are also included, such as the date of his appointment and employer's name and address. The form requests information on any previous employment. Finally, family particulars are listed including his father Ramesh Bhana Parmar's name, date of birth, relationship, and that he resides with Yogesh.

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    Declaration Form - Employees’ State Insurance Corporation (ESIC) (1)

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    Yogesh Ramesh Parmar declares insurance details including personal information like name, date of birth, address, and family details. He provides his father Ramesh's name, declares his marital status as single, and notes his permanent and present addresses. Details of his employer are also included, such as the date of his appointment and employer's name and address. The form requests information on any previous employment. Finally, family particulars are listed including his father Ramesh Bhana Parmar's name, date of birth, relationship, and that he resides with Yogesh.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    11 views2 pages

    Declaration Form - Employees' State Insurance Corporation (ESIC)

    Uploaded by

    global news
    Yogesh Ramesh Parmar declares insurance details including personal information like name, date of birth, address, and family details. He provides his father Ramesh's name, declares his marital status as single, and notes his permanent and present addresses. Details of his employer are also included, such as the date of his appointment and employer's name and address. The form requests information on any previous employment. Finally, family particulars are listed including his father Ramesh Bhana Parmar's name, date of birth, relationship, and that he resides with Yogesh.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    13526758

    DECLARATION FORM Form No -1

    To be filled in by the employee please use only capital letters

    (A) INSURED PERSON'S PARTICULARS

    1. insurance No.
    2.Name in block letters YOGESH RAMESH PARMAR
    3. Father's / Husband's Name Father: Ramesh
    4.Date of Birth 03/07/2000
    4. (a)Disability Status Y N
    5 Marital Status SINGLE

    6.Sex MALE
    7.Present Address R NO 361 KHAR DANDA, PATIL PADA NEAR DATTA MANDIR
    400052

    Pincode
    Mobile No 9136280552
    Email Id YOGESHPARMAR12377@GMAIL.COM
    8.Permanent Address R NO 361 KHAR DANDA, PATIL PADA NEAR DATTA MANDIR
    400052

    Pincode
    Mobile No
    Email Id
    (B)EMPLOYER'S PARTICULARS
    9.Employer's Code No
    10.Date of Appointment 22/07/2022
    11.Name & address of the employer
    12.In case of any previous employment please fill up the below
    details

    a.Previous Insu.No
    b.Employer's Code No

    c.Name & address of the employer

    (C) Details of the Nominee

    a. Name
    b.Relationship
    c.Address

    (D) Family particulars of Insured person


    Whether
    Relationship With Residing If No State of place of
    SR.No Name Date of Birth/Age
    the Employee with him Residence
    /her

    Yes No Town State

    1 RAMESH BHANA PARMAR 03/11/1970 FATHER Yes

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