EMPLOYEES’ STATE INSURANCE CORPORATION

Return of Declaration Form

Regulation 14

Name & Address of Factory or Establishment

O.P JINDAL BHARATI VIDYA MANDIR
JINDAL NAGAR,

KOTHAVALASA, VILLAGE & MANDAL,

VIZIANAGARAM

Employer's Code No. 70000516620001302

I send herewith Declaration Forms in respect of the employees mentioned below. I hereby declare that 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 is respect of a remuneration not exceeding Rs. 15,000/-
(excluding remuneration for overtime work) per month has been included in this list (excepting only those in respect of
whom declaration forms have been sent to the Corporation in the past).

Place Local Office

Date 17/9/2022 Designation

Sl No Employee Name Insurance No. From Date. To Date. Exemption Status. Registration Date

1 ADAPALA SANTHI 7011246448 -- -- NO 10-08-2022

2 ALLAKA DHILLEESWARI 7010355847 -- -- NO 21-03-2018

3 AMANAPU TEJA 7011232338 -- -- NO 21-07-2022

4 APPIKONDA UMAMAHESWARI 7010317410 -- -- NO 03-01-2018

5 B TRIMURTHULU 7009816661 -- -- NO 22-02-2015

6 B VIJAYA ANU RADHA 7010046039 -- -- NO 15-10-2016

7 BALIREDDY GOVINDA 7009816449 -- -- NO 21-02-2015

Page 1 of 5
Sl No Employee Name Insurance No. From Date. To Date. Exemption Status. Registration Date

8 BANDI VIJAYA LAKSHMI 7010436798 -- -- NO 11-08-2018

9 BODDU VENKATA RAO 7010457798 -- -- NO 14-09-2018

10 CH GANGA LAKSHMI 7010046153 -- -- NO 15-10-2016

11 CH TATA RAO 7010046196 -- -- NO 15-10-2016

12 CH UMA SUDHA RANI 7009816724 -- -- NO 22-02-2015

13 CHIRLA PHAVANI 7011227564 -- -- NO 14-07-2022

14 CHOPPA REVATHI 7011244427 -- -- NO 08-08-2022

15 DANDI NARAYANA MURTHY 7009816525 -- -- NO 21-02-2015

16 DANNINA HEMALATHA 7011076017 -- -- NO 09-10-2021

17 DEVARAPALLI KRISHNAVENI 7009816146 -- -- NO 20-02-2015

18 DONKAD ASRINIVASA RAO 7011230511 -- -- NO 19-07-2022

19 ERRA VENKATA NARASIMHA 7010925220 -- -- NO 29-12-2020

20 G GOVINDA 7009816668 -- -- NO 22-02-2015

21 G VENKATESWARA RAO 7009816676 -- -- NO 22-02-2015

22 GEDELA MUTYALU 7011224278 -- -- NO 08-07-2022

23 GEDELA SUDHA 7011227488 -- -- NO 14-07-2022

Page 2 of 5
Sl No Employee Name Insurance No. From Date. To Date. Exemption Status. Registration Date

24 GORLE CHANDRIKANAIDU 7010637751 -- -- NO 11-07-2019

25 GUMADI AVATARAM 7009816571 -- -- NO 21-02-2015

26 JAMI UMAMAHESWARA RAO 7010417528 -- -- NO 13-07-2018

27 K NAGA MANI 7010046206 -- -- NO 15-10-2016

28 K RAMBABU 7009816691 -- -- NO 22-02-2015

29 KAPU KANAKA DURGA 7010436782 -- -- NO 11-08-2018

30 KRISHNA VENI PENTAKOTA 7011107691 -- -- NO 08-12-2021

31 KUNCHA DEMUDUBABU 7011224296 -- -- NO 08-07-2022

32 LAGUDU MAHESH 7010045809 -- -- NO 15-10-2016

33 LENKA ESWARARAO 7011068720 -- -- NO 28-09-2021

34 LENKA SATYANARAYANA 7010678268 -- -- NO 31-08-2019

35 M SANDHYA 7009816655 -- -- NO 22-02-2015

36 M TRINADHA 7009816684 -- -- NO 22-02-2015

37 MAHANTHI CHIRANJEEVI 7010167887 -- -- NO 08-07-2022

38 MAROJU SREE DEVI 7011224304 -- -- NO 08-07-2022

39 MEDISETTI KOTESWARARAO 7010637721 -- -- NO 11-07-2019

Page 3 of 5
Sl No Employee Name Insurance No. From Date. To Date. Exemption Status. Registration Date

40 MEESALA UMA MAHESWARI 7011152886 -- -- NO 03-03-2022

41 MIDATHANA RAMASWAMY 7011152901 -- -- NO 03-03-2022

42 MUDIMUNCHI SADHANA 7010244483 -- -- NO 12-03-2019

43 N CHELLAYYAMMA 7009816703 -- -- NO 22-02-2015

44 NAMBARU APPALA NAIDU 7009816549 -- -- NO 21-02-2015

45 NARINDI BABASRINUVAS 7011236724 -- -- NO 27-07-2022

46 P APPALA NAIDU 7009816659 -- -- NO 22-02-2015

47 P JYOTHI 7010046100 -- -- NO 15-10-2016

48 P SRINU 7009816657 -- -- NO 22-02-2015

49 P.RAMANA RAJU 7009370218 -- -- NO 14-04-2022

50 PADMA LOCHAN OJHA 7005618612 -- -- NO 22-06-2020

51 PAMPANA KISHORE 7010045989 -- -- NO 15-10-2016

52 PANTHINI DEEPA 7011075998 -- -- NO 09-10-2021

53 PEDIREDLA SANKARARAO 7011237408 -- -- NO 28-07-2022

54 PILAKA V S S VISWANADHAM 7010231362 -- -- NO 13-07-2017

55 POLAMARASETTY BHEEMESWARAMMA
7009816498 -- -- NO 21-02-2015

Page 4 of 5
Sl No Employee Name Insurance No. From Date. To Date. Exemption Status. Registration Date

56 PRAVATI OJHA 7010967324 -- -- NO 17-03-2021

57 PULIBANTI APPALA NAIDU 7009816053 -- -- NO 20-02-2015

58 SANABANI UMA 7011230533 -- -- NO 19-07-2022

59 SARIPALLI RAMAKRISHNA 7010663368 -- -- NO 12-08-2019

60 SINGAMPALLI BHASKARARAO 7010231430 -- -- NO 13-07-2017

61 SINGAMPALLI RAMBABU 7010417730 -- -- NO 13-07-2018

62 SIRIKI RAMANA 7011252272 -- -- NO 22-08-2022

63 SIRISIPALLI MANASA 7011224318 -- -- NO 08-07-2022

64 SURESH PILLA 5213466651 -- -- NO 12-05-2022

65 V SOUMYA 7010046138 -- -- NO 12-08-2019

66 VECHALAPU RAMU NAIDU 7010663409 -- -- NO 12-08-2019

67 VISWANADHU DIVYA 7010231374 -- -- NO 12-03-2019

68 VUPPALA NARAYANA RAO 7009816047 -- -- NO 13-08-2016

69 Y ESWARA RAO 7009816697 -- -- NO 22-02-2015

70 Y LAKSHMI LATHA 7009816730 -- -- NO 22-02-2015

Page 5 of 5