EMPLOYEES' STATE INSURANCE CORPORATION

e-Pehchan Card

PERSONAL DETAILS

Name of IP : HARIBALLAV BEHERA Insurance No. : 4405252566

Date of Birth : 04/02/1983 UHID : OR01.0002571030
Gender : Male UAN : 100708128040
Mobile Number : 7077211781 ABHA Number : NA
Email ID : NA ABHA Address : NA
Registration Date : 17/01/2021 Aadhaar : NA

REGISTRATION DETAILS

Marital Status : Unmarried Name of Father / : BANKANIDHI BEHERA

Husband
Type Of Disability : NA
Present Address : DANGADI,Dist:Jajapur (Jajpur),Odisha Permanent Address : DANGADI,Dist:Jajapur
(Jajpur),Odisha

Dispensary / : Jajpur road, OR (ESIS Disp.) Dispensary / : Jajpur road, OR (ESIS Disp.)
IMP for IP IMP for Family

CURRENT EMPLOYER DETAILS

Employer's Code : 44000173670001001 Name of Employer : S.K. BOSE

No.

Sub Unit's Code : None Date of : 19/11/2022

No. Appointment

Address of : SHREE BHAGWAN Branch Office : BO - Jajpur Road,Branch

Employer CHOUDHARY,PROP.,AT-DHABALAGIRI( Office, ESI Corporation, H/o
Smt. Sipra Sahoo,Near
NA Indira

FAMILY DETAILS

Name Relation Date UHID/ABHA Number ABHA UAN/ Is Residing State/District

with of Birth Address Aadhaar with IP
IP

Odisha /
RINA BEHERA Spouse 25/05/1991 OR01.0002571033/N NA Yes
A
Jajapur (Jajpur)

Page 1 of 2
 Odisha /
SAI BEHERA Minor 04/01/2016 OR01.0002571034/N NA Yes
dependant son A
Jajapur (Jajpur)

NOMINEE DETAILS

UHID/
Name of Nominee Relation with IP Date of Birth Address of Nominee Percentage(%)
ABHA Number

JAJAPUR,OdishaDist:Jajapu
BANKANIDHI Dependant father NA NA r (Jajpur) 100
BEHERA

Affix Your Family Photograph Here. (Attested and Stamped by

Employer / ESIC Official)

Signature / LTI of Registered Employee / IP

Signature / Stamp of ESIC Officer / Employer

Note:
· This e-Pehchan card affixed with photograph of family & duly attested by the Employer/ESIC Staff shall be requested for
availing cash/medical benefit.
· e-Pehchan card is a proof of registration under ESI scheme. However eligibility for various benefits depends upon the
contribution conditions. For further information on eligibility to various Benefits, please visit- www.esic.in

Printed By (Employer/User Name) : S.K. BOSE

IP Number : 4405252566
Address : DANGADI,Dist:Jajapur (Jajpur),Odisha

Date : 06/01/2024 9:09:50PM

Page 2 of 2