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Edit Name and Dispensary Details * Required Fields

Insured Person's Number : 4404293867

Dispensary Or IMP or mEUD for IP:*
State: Odisha District: Jajapur (Jajpur)

Medical Officer Incharge, E.S.I.

Dispensary IMP mEUD Duburi, OR (ESIS Disp.) Address: Dispensary, Duburi,At/PO:-
TrijangaHousing Colony
Dispensary Or Imp or mEUD for Family:*
State: Odisha District: Kendujhar (Keonjhar)

Medical Officer Incharge, ESI

Dispensary IMP mEUD Brahmanipal, OR (ESIS Disp.) Address: Dispensary, At P.O.-Brahmanipal, Dist-
Keonjhar Pin 758082

This is to certify that I have meticulously examined the request made by the beneficiary and the supported documents / evidences for changing the assigned Primary Care Centre (Dispensary
/IMP Clinic/ EUD /DCBO, etc). I am satisfied with the justifications given and the reasons explained by the beneficiary for the above request. I understand that the explanations provided by the
beneficiary are reasonable and are within the specified criteria. I strongly recommend the above change note with standing that I shall be liable for actions for submission of false or incorrect
information. *
The reference number 442451505098 has been generated and pending for approval.

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 EMPLOYEES' STATE INSURANCE CORPORATION
e-Pehchan Card

PERSONAL DETAILS

Name of IP : HAREKRUSHNA BINDHANI Insurance No. : 4404293867

Date of Birth : 28/12/1989 UHID : NA
Gender : Male UAN : NA
Mobile Number : 8328935781 ABHA Number : NA
Email ID : NA ABHA Address : NA
Registration Date : 30/05/2018 Aadhaar : NA

REGISTRATION DETAILS

Marital Status : Married Name of Father / : Madhusudan Bindhani

Husband
Type Of Disability : NA
Present Address : Kantipal,Kantipal,Kantipal,Dist:Kendujhar Permanent Address : Kantipal,Kantipal,Kantipal,Dist:
(Keonjhar),Odisha,758021 Kendujhar
(Keonjhar),Odisha,758021

Dispensary / : Brahmanipal, OR (ESIS Disp.) Dispensary / : Brahmanipal, 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 : 17/11/2023

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 Indira

FAMILY DETAILS

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

with of Birth Address Aadhaar with IP
IP

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 NOMINEE DETAILS

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

Kantipal,Kantipal,Kantipal,O
Madhusudan Dependant father NA NA dishaDist:Kendujhar 100
Bindhani (Keonjhar)758021

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 : 4404293867
Address : Kantipal,Kantipal,Kantipal,Dist:Kendujhar (Keonjhar),Odisha,758021

Date : 15/05/2024 12:07:46PM

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