¡òɨÉÇ-1

FORM – I
PÉÉä¹ÉhÉÉ {ÉīÉ DECLARATION FORM
PÉÉä¹ÉhÉÉ {ÉǐÉ Eò¨ÉÇSÉÉ®úÒ uùÉ®úÉ ¦É®úÉ VÉÉBMÉÉ * ¡òɨÉÇ Eäò ºÉÉlÉ {ÉɺÉ{ÉÉä]Çõ +ÉEòÉ®ú Eäò nùÉä ¡òÉä]õÉäOÉÉ¡ò ¦ÉÒ ±ÉMÉÉB VÉÉxÉä SÉÉʽþB * ¡òɨÉÇ ¦É®úxÉä ºÉä {ɽþ±Éä
{ÉÒ`ö {ÉÞ¹`ö {É®ú nùÒ MÉ<Ç Ê½þnùɪÉčÉÉå EòÉä ¦É±ÉÒ-¦ÉÉÆÊčÉ {Égø ±ÉäxÉÉ SÉÉʽþB * ªÉ½þ ¡òɨÉÇ ÊxÉ:¶ÉÖ±Eò ½èþ*
To be filled in by the employee after reading instructions overleaf. Two Postcard Size photographs are to be attached
with this form. This form is free of cost.
(Eò) ¤ÉÒ¨ÉÉEÞòiÉ ´ªÉÊHò EòÉ Ê´É´É®úhÉ (JÉ) ÊxɪÉÉäVÉEò EòÉ Ê´É´É®úhÉ
(A)INSURED PERSON’s PARTICULARS (B)EMPLOYER’S PARTICULARS
1. ¤ÉÒ¨ÉÉ ºÉÆJªÉÉ/Insurance No.

2. xÉÉ¨É (º{ɹ]õ +IÉ®úÉå ¨Éå )

Name (in block letters)

3. Ê{ÉčÉÉ/{ÉÊčÉ EòÉ xÉɨÉ

Father’s/Husband’s Name

4. VÉx¨É ÊčÉÊlÉ/Date of Birth ÊnùxÉ ¨É½þÒxÉÉ ´É¹ÉÇ 5. ´Éè´ÉÉʽþEò ºčÉ®ú Ê´É´ÉÉʽþčÉ/

D M Y Marital Status +Ê´É´ÉÉʽþčÉ/Ê´ÉvÉ´ÉÉ
M/U/W

6. ˱ÉMÉ /Sex {ÉÖ./¨É.M/F

7. ´ÉčÉǨÉÉxÉ {ÉčÉÉ/Present Address 8. ºlÉɪÉÒ {ÉčÉÉ/ Permanent Address

Ê{ÉxÉ EòÉäb÷ Ê{ÉxÉ EòÉäb÷

Pin Code Pin Code

]äõ±ÉÒ¡òÉäxÉ xɨ¤É®ú/<Ç-¨Éä±É xÉƤɮúú/e-mail address ]äõ±ÉÒ¡òÉäxÉ xɨ¤É®ú/<Ç-¨Éä±É xÉƤɮú/e-mail address

¶ÉÉJÉÉ EòɪÉÉÇ±ÉªÉ +Éè¹ÉvÉɱɪÉ

Branch Office Dispensary

9. ÊxɪÉÉäVÉEò EòÒ EÚò]õ ºÉÆJªÉÉ

Employer’s Code No.

10. ÊxɪÉÖÊHò EòÒ ÊčÉÊlÉ ÊnùxÉ ¨É½þÒxÉÉ ´É¹ÉÇ

Date of Appointment Day Month Year

11. ÊxɪÉÉäVÉEò EòÉ xÉÉ¨É +Éè®ú {ÉčÉÉ/Name & Address of the Employer

12. ªÉÊnù {ɽþ±Éä ÊxɪÉÉäVÉxÉ ¨Éå ®ú½äþ ½éþ čÉÉä EÞò{ɪÉÉ ÊxɨxÉʱÉÊJÉčÉ Ê´É´É®úhÉ nùÒÊVÉB
In case of any previous employment please fill up the details
as under:-
Eò) Ê{ÉUô÷±ÉÒ ¤ÉÒ¨ÉÉ ºÉÆJªÉÉ
a) Previous Ins. No.
JÉ) ÊxɪÉÉäVÉEò EÚò]õ ºÉÆJªÉÉ
b) Emplr’s. Code No.
MÉ) ÊxɪÉÉäVÉEò EòÉ xÉÉ¨É ´É {ÉÚhÉÇ {ÉčÉÉ
c) Name & address of the Employer

]äõ±ÉÒ¡òÉäxÉ xɨ¤É®ú/<Ç-¨Éä±É xÉƤɮú/e-mail address

(MÉ) ¨ÉÞčªÉÖ EòÒ ÎºlÉÊčÉ ¨Éå xÉEònù ʽþčɱÉÉ¦É Eäò ¦ÉÖMÉčÉÉxÉ Eäò ʱÉB Eò.®úÉ.¤ÉÒ. +ÊvÉÊxÉªÉ¨É 1948 EòÒ vÉÉ®úÉ 71/Eò.®úÉ.¤ÉÒ. (EäòxpùÒªÉ) ÊxÉªÉ¨É 1950 Eäò ÊxÉªÉ¨É 56(2) Eäò +xčÉMÉÇčÉ xÉÉʨÉčÉ Eäò ¤ªÉÉä®äú*
(C) Details of Nominee u/s 71 of ESI Act 1948/Rule 56(2) of ESI (Central) Rules, 1950 for payment of cash benefit in the event of death.
xÉÉ¨É /Name ºÉƤÉÆvÉ/Relationship {ÉčÉÉ /Address

¨Éé PÉÉä¹ÉhÉÉ Eò®účÉÉ/Eò®účÉÒ ½ÚÆþ ÊEò ¨Éä®äú uùÉ®úÉ |ɺčÉÖčÉ ÊEòªÉÉ MɪÉÉ ¤ªÉÉè®úÉ ¨Éä®úÒ VÉÉxÉEòÉ®úÒ +Éè®ú Ê´É·ÉÉºÉ Eäò +xÉÖºÉÉ®ú ºÉ½þÒ ½èþ * ¨Éé +{ÉxÉä {ÉÊ®ú´ÉÉ®ú Eäò ºÉnùºªÉÉå ¨Éå ½ÖþB {ÉÊ®ú´ÉčÉÇxÉ EòÒ ºÉÚSÉxÉÉ 15 ÊnùxÉ Eäò ¦ÉÒčÉ®ú |ɺčÉÖčÉ Eò®úxÉä
EòÉ ´ÉSÉxÉ ¦ÉÒ näùčÉÉ/näùčÉÒ ½ÚÆþ *
I hereby declare that the particulars given by me are correct to the best of my knowledge and belief. I undertake to intimate the Corporation any changes in the
membership of my family within 15 days of such change.

ÊxɪÉÉäVÉEò Eäò |ÉÊčɽþºčÉÉIÉ®ú

Counter signature by the employer
¤ÉÒ¨ÉÉEÞòčÉ ´ªÉÊHò Eäò ½þºčÉÉIÉ®ú/+ÆMÉÚ`öÉ ÊxɶÉÉxÉ
½þºčÉÉIÉ®ú/ºÉÒ±É Signature/T.I. of IP
Signature with seal
(PÉ) ¤ÉÒ¨ÉÉEÞòčÉ ´ªÉÊHò Eäò {ÉÊ®úVÉxÉÉå EòÉ Ê´É´É®úhÉ/
(D) FAMILY PARTICULARS OF INSURED PERSON
Gò.ºÉÆ. xÉÉ¨É ¡òɨÉÇ ¦É®úxÉä EòÒ čÉÉ®úÒJÉ EòÉä +ɪÉÖ Eò¨ÉÇSÉÉ®úÒ Eäò ºÉÉlÉ ºÉƤÉÆvÉ CªÉÉ =xÉEäò ºÉÉlÉ ®ú½þ ®ú½äþ ½éþ ªÉÊnù xɽþÓ čÉÉä +É´ÉÉºÉ EòÉ ºlÉÉxÉ nù¶ÉÉÇBÆ
Sl. No. Name Date of Birth/Age as on Relationship with the Whether residing If ‘No’, state place of Residence
date of filling form Employee with him/her?
1. ½þÉÄ/Yes xɽþÓ/No ={É xÉMÉ®ú/Town ®úÉVªÉ/State
2.
3.
4.
5.
6.
7.
8.

……………………………………………………………………………………………………………………………
Eò.®úÉ.¤ÉÒ. ÊxÉMɨÉ
+ºlÉɪÉÒ {ɽþSÉÉxÉ {ÉǐÉ (ÊxɪÉÖÊHò EòÒ ÊčÉÊlÉ ºÉä 3 ¨ÉÉºÉ čÉEò ´Éèt)
ESI Corporation (valid for 3 months from the date of appointment)
Temporary Identity Card

xÉɨÉ/Name

¤ÉÒ¨ÉÉ ºÉÆJªÉÉ/Ins. No. ÊxɪÉÖÊHò EòÒ ÊčÉÊlÉ/Date of appointment

º´ÉªÉÆ B´É¨É {ÉÊ®ú´ÉÉ®ú EòÉ ¡òÉä]õÉäOÉÉ¡ò
(Space for photograph)
¶ÉÉJÉÉ EòɪÉÉÇ±ÉªÉ +Éè¹ÉvÉɱɪÉ
Branch Office Dispensary
ÊxɪÉÉäVÉEò EòÒ EÚò]õ ºÉÆJªÉÉ ´É {ÉčÉÉ
Employer’s Code No. & Address

´ÉèvÉčÉÉ:
Validity:

ÊnùxÉÉÆEò :
Dated : ¤ÉÒ¨ÉÉEÞòčÉ ´ªÉÊHò Eäò ½þºčÉÉIÉ®ú/+ÆMÉÚ`äö EòÉ ÊxɶÉÉxÉ ¨ÉÉä½þ®ú ºÉʽþiÉ ¶ÉÉJÉÉ EòɪÉÉÇ±ÉªÉ |ɤÉÆvÉEò Eäò ½þºiÉÉIÉ®ú
Signature/T.I of I.P Signature of B.M. with seal
 +xÉÖnäù¶É
INSTRUCTIONS

1. ¡òɨÉÇ-1 EòÉ |Éä¹ÉhÉ Eò.®úÉ.¤ÉÒ. (ºÉÉvÉÉ®úhÉ) Ê´ÉÊxɪɨÉɴɱÉÒ-1950 Eäò Ê´ÉÊxÉªÉ¨É 11 ´É 12 Eäò +xčÉMÉÇčÉ Ê´ÉÊxɪÉʨÉčÉ ÊEòªÉÉ VÉÉčÉÉ ½èþ*
Submission of Form-I is governed by regulations 11 & 12 of ESI (General)Regulations, 1950.

2. {ÉÊ®ú´ÉÉ®ú EòÉ +lÉÇ ½èþ (1) {ÉÊčÉ/{ÉčxÉÒ (2) ¤ÉÒ¨ÉÉEÞòčÉ ´ªÉÊHò EòÒ +ÉªÉ {É®ú +ÉÊAÉčÉ ´ÉèvÉ +lÉ´ÉÉ MÉÉänù ʱɪÉä +´ÉªÉºEò ¤ÉSSÉä/+Ê´É´ÉÉʽþčÉ {ÉÖǐÉÒ
(3) 21 ´É¹ÉÇ EòÒ +ɪÉÖ čÉEò ¤ÉÒ¨ÉÉEÞòčÉ ´ªÉÊHò {É®ú +ÉÊAÉčÉ ´ÉèvÉ +lÉ´ÉÉ MÉÉänù ʱɪÉÉ ½Öþ+É ´ªÉºEò ¤ÉSSÉÉ ªÉÊnù ʶÉIÉÉ |ÉÉ{´čÉ Eò®ú ®ú½þÉ ½þÉä (4)
{ÉÚ®úÒ čÉ®ú½þ ¤ÉÒ¨ÉÉEÞòčÉ ´ªÉÊHò EòÒ +ÉªÉ {É®ú ÊxɦÉÇ®ú +¶ÉHò ¤ÉSSÉÉ (5) +ÉÊAÉčÉ ¨ÉÉčÉÉ-Ê{ÉčÉÉ Eò.®úÉ.¤ÉÒ. +ÊvÉÊxÉªÉ¨É EòÒ vÉÉ®úÉ-2 Eäò +xčÉMÉÇčÉ
{ÉÊ®ú¦ÉÉʹÉčÉ +Éè®ú ºlÉÉxÉÒªÉ {ÉÊ®ú´ÉÉ®úVÉxÉ ÊSÉÊEòčºÉÉ näùJÉ®äúJÉ Eäò ½þEònùÉ®ú ½éþ*
“Family” means all or any of the following relatives of an Insured Person namely:-
(i) a spouse (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a child who is wholly
dependant on the earnings of the I.P. and who is (a) receiving education, till he or she attains the age of 21 years
(b) an unmarried daughter ; (iv) a child who is infirm by reason of any physical or mental abnormality or injury
and is wholly dependant on the earnings of the I.P. so long as the infirmity continues; (v) dependant parents
(Please see Section 2 clause 11 of the ESI Act 1948 for details).

3. {ɽþSÉÉxÉ-{ÉǐÉ +½þºčÉÉxčÉ®úhÉÒªÉ ½èþ*

Identity Card is Non-transferable.

4. {ɽþSÉÉxÉ-{ÉǐÉ MÉÖ¨É ½þÉäxÉä EòÒ ÎºlÉÊčÉ ¨Éå ÊxɪÉÉäVÉEò/¶ÉÉJÉÉ EòɪÉÉÇ±ÉªÉ |ɤÉÆvÉEò EòÉä čÉčEòÉ±É ºÉÚÊSÉčÉ ÊEòªÉÉ VÉÉB *
Loss of Identity Card be reported to Employer/Branch Manager immediately.

5. ÊEòºÉÒ |ÉEòÉ®ú EòÒ MɱÉčÉ ºÉÚSÉxÉÉ näùxÉä EòÒ ÎºlÉÊčÉ ¨Éå Eò.®úÉ.¤ÉÒ. +ÊvÉÊxɪɨÉ-1948 EòÒ vÉÉ®úÉ-84 Eäò čɽþčÉ EòÉxÉÚxÉúÒ EòɪÉÇ´ÉɽþÒ EòÒ VÉÉ ºÉEòčÉÒ
½èþ*
Submission of false information attracts penal action under Section 84 of ESI Act, 1948.

6. xÉ<Ç ÊxɪÉÖÊHò EòÒ ÎºlÉÊčÉ ¨Éå ¦É±ÉÒ-¦ÉÉÆÊčÉ ¦É®úÉ ½Öþ+É ªÉ½þ ¡òɨÉÇ ÊxɪÉÖÊHò Eäò nùºÉ ÊnùxÉ Eäò ¦ÉÒčÉ®ú ºÉƤÉÆÊvÉčÉ ºlÉÉxÉÒªÉ EòɪÉÉÇ±ÉªÉ ¨Éå +´É¶ªÉ ½þÒ
|ɺčÉÖčÉ ÊEòªÉÉ VÉÉxÉÉ SÉÉʽþB* ʴɱɨ¤É EòÒ ÎºlÉÊčÉ ¨Éå ÊxɪÉÉäVÉEò Eäò Ê´Évürù vÉÉ®úÉ-85 Eäò čɽþčÉ EòÉxÉÚxÉÒ EòɪÉÇ´ÉɽþÒ EòÒ VÉÉ ºÉEòčÉÒ ½èþ*
This form duly filled in must reach the concerned Branch Office within 10 days of appointment of an
Employee. Delay attracts penal action under Section 85 of the Act, against employer.

7. ¤ÉÒ¨ÉÉEÞòčÉ ´ªÉÊHò +ƶÉnùɪÉÒ ¶ÉčÉæ {ÉÚ®úÒ Eò®úxÉä {É®ú ÊxɨxÉʱÉÊJÉčÉ Ê½þčɱÉÉ¦É |ÉÉ{čÉ Eò®ú ºÉEäòMÉÉ (1) ¤ÉÒ¨ÉÉ®úÒ Ê½þčɱÉÉ¦É (2) +ºlÉɪÉÒ +{ÉÆMÉčÉÉ
ʽþčɱÉÉ¦É (3) ºlÉɪÉÒ +{ÉÆMÉčÉÉ Ê½þčɱÉÉ¦É (4) +ÉÊAÉčÉ VÉxÉ Ê½þčɱÉÉ¦É (5) |ɺÉÚÊčÉ Ê½þčɱÉÉ¦É (¨Éʽþ±ÉÉ Eò¨ÉÇSÉÉ®úÒ Eäò ʱÉB)*
As an Insured Person you and your dependent family members are entitled to full medical care. The other
benefits in cash include (1) Sickness Benefit (2) Temporary Disablement benefit (3) Permanent disablement
Benefit (4) Dependents benefit and (5) Maternity Benefit (in case of women employees) subject to fulfillment
of contributory conditions.

8. +ÊvÉEò VÉÉxÉEòÉ®úÒ Eäò ʱɪÉä ÊxÉMÉ¨É Eäò ´Éä¤ÉºÉÉ<]õ www.esic.org.in EòÉä näùJÉå ªÉÉ ºlÉÉxÉÒªÉ EòɪÉÉÇ±ÉªÉ ªÉÉ IÉäÊǐÉªÉ EòɪÉÉÇ±ÉªÉ ºÉä ºÉ¨{ÉEÇò
Eò®åú*
For more details please visit website of ESIC at www.esic.org.in or contact Regional office or Branch
Office.

Eäò´É±É ¶ÉÉJÉÉ EòɪÉÉÇ±ÉªÉ ¨Éå |ɪÉÉäMÉ ½äþiÉÖ

FOR BRANCH OFFICE USE ONLY

1. ¤ÉÒ¨ÉÉ ºÉÆJªÉÉ +ɤÉÆ]õxÉ EòÒ čÉÉ®úÒJÉ :

Date of Allotment of Ins. No. :
2. +.{É.{É. VÉÉ®úÒ Eò®úxÉä EòÒ čÉÉ®úÒJÉ :
Date of Issue of TIC :

3. +Éè¹ÉvÉÉ±ÉªÉ EòÉ xÉɨÉ/ºÉÆJªÉÉ :

Name/No. of Disp. :

4. CªÉÉ +xªÉ ÊSÉÊEòčºÉÉ ´ªÉ´ÉºlÉÉ ={ɱɤvÉ ½èþ,? ªÉÊnù ½þÉÆ, čÉÉä =±±ÉäJÉ Eò®åú :
Whether reciprocal Medical arrangements involved? If yes, please indicate:
………………………………………............………………..

|ɤÉxvÉEò Eäò ½þºčÉÉIÉ®

Signature of Branch Manager

Gò.ºÉÆ. xÉÉ¨É ¡òɨÉÇ ¦É®úxÉä EòÒ čÉÉ®úÒJÉ EòÉä +ɪÉÖ Eò¨ÉÇSÉÉ®úÒ Eäò ºÉÉlÉ ºÉƤÉÆvÉ CªÉÉ =xÉEäò ºÉÉlÉ ®ú½þ ®ú½äþ ½éþ ªÉÊnù xɽþÓ čÉÉä +É´ÉÉºÉ EòÉ ºlÉÉxÉ nù¶ÉÉÇBÆ
Sl. No. Name Date of Birth/Age as on Relationship with the Whether residing If ‘No’, state place of Residence
date of filling form Employee with him/her?
1. ½þÉÄ/Yes xɽþÓ/No ={É xÉMÉ®ú/Town ®úÉVªÉ/State
2.
3.
4.
5.
6.
7.
8.