FOR EMPLOYEES REGISTRATION FORM

Insured Person's Particulars (BELOW MENTIONED INFORMATI

Is IP Disabled:*
1.(b) Type of Disability:
1.(c) Select Certificate:

2. Name:*
3. Name of* (FATHER)
4. Date of Birth:*
5. Marital Status:* (UNMARRIED/ MARRIED/ WIDOW/
WIDOWER)
6. Gender:* (M/ F/ TG)

7. Present Address
Address :*
State:*
District:*
Pin Code:
Mobile No.*:
Email:

8. Permanent Address
Address :*
State:*
District:*
Pin Code:
Mobile No.*:
Email:

9 a. Dispensary Or IMP or mEUD For IP:*

State:
District:
Name of ESIC Dispensary/ IMP/ mEUD For IP:*

9 b. Dispensary Or IMP or mEUD for Family Members:*

State:
District:
Name of ESIC Dispensary/ IMP/ mEUD For Family Members:*

10. Current Employer's Particulars

Date of Appointment:* (DOJ)
11.(a) Have Previous Employer:
11.(b) In case of any Previous employment please fill up the
details below:
Employer's Code No.:
Previous Insurance No.:
Name of the Employer:*
Address of the Employer
State:
District:
Pin Code:

12. Details of Nominee :*

Name :*
Date of Birth :*
Relationship with Insured Person :*
Address of Nominee
Address :*
State :*
District :*
Pincode :
Is Nominee a Family Member :

13. Family Particulars of Insured Person: (SPOUSE/DEPENDENT

FATHER/ DEPENDENT MOTHER/ MINOR DEPENDENT SON/
DEPENDENT UNMARRIED DAUGHTER)

Name*
Date of Birth*
Relationship with the Employee*
Gender:* (M/ F/ TG)
Whether Residing with Him / Her?

14. Details of Bank Accounts of Insured Person:

Account Number*
Type Of Account* (CURRENT/ OTHERS/ SAVING)
Name Of Bank*
Name Of Branch*
MICR Code of the Bank/Branch
IFSC Code of the Bank/Branch*

NOTE :- * Required Fields (all the required fields

FOR EMPLOYEES REGISTRATION FORM 1
Particulars (BELOW MENTIONED INFORMATIONS ARE REQUIRED)
NO

Tazzamul Shafique
Sadullah Ahmed
10/2/1996
Unmarried
Male

House No. 14, Pragati Path, Chandan Nagar, Bhetapara, Guwahati

Assam
Kamrup (M)
781028
7399694610
tshafique56@gmail.com

do

Assam
Kamrup (M)
ESIC Dispensary Dispur

2/15/1996
 Sadullah Ahmed
3/1/1970
Father

House No. 14, Pragati Path, Chandan Nagar, Bhetapara, Guwahati

Assam
Kamrup (M)
781028
Yes

Sadullah Ahmed Jahanara Begum X

3/1/1970 8/31/1976 00-00-0000
Father Mother
M F
Yes Yes

20268030338
SAVING
SBI
IIBM KHANAPARA

SBIN0010669

d Fields (all the required fields need to be filed up)