REG. Form-2 ADDITION/DELETION IN FAMILY DECLARATION FORM EMPLOYEE'S STATE INSURANCE CORPORATION (Regulation 15B) Name of the Insured Person__________________________-Insurance No. I declare that the person/persons whose particulars are given below has/have now become/ceased to be member(s) of my family*. Si. No. Name Date of Birth Reason(s) for change & date Realationship with the insured Person Whether residing with him/her or not state If no, where residing Name of IMP/Disp. attached. Yes No. Distt. State I hereby declare that the particulars given above are true to the best of my knowledge and belief. Necessary changes may kindly be made in my Declaration Form submitted earlier. Passport size photographs of the members who are added to family is/are enclosed. Place.................................... Date...................................... ........................................................................... Signature/thumb impression of the employee Name in Block letters_____________________ Particulars of the Employer:- Name :____________________________ Addres :___________________________ Countersignatue of the employer ___________________________________ Code No.____________________________ ..................................................... Desgnation with Rubber Stamp Note : "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) *Please submit duly attested copy of the Birth/Death Certificate. fofu-iz:i&2 dqVqEc ?kks"k.kk iz:i esa ifjorZu deZpkjh jkT; chek fuxe ¼fofu;e 15 [k½ chekÑr O;fDr dk uke------------------------------------------------------------------------------chek la[;k eSa blds }kjk ;g ?kks"k.kk djrk gwa fd og@os O;fDr ftlds@ftuds fooj.k uhps fn, x, gSa vc esjs dqVqEc dk@ds lnL;@gks x;k gS@x, gSa@ vc esjs dqVqEc dk@ds lnL; ugha gS@gSaA¹ Øla uke tUe dh rkjh[k ifjorZu dk dkj.k o rkjh[k chekÑr O;fDr ds lkFk ukrsnkjh D;k mlds lkFk fuokl dj jgk gS@ jgh gSa ;k ughaA ;fn ugha] rks dgka fuokl dj jgk gSA lEc) chek fpfdRlk O;olk;h@ vkS"k/kky; dk uke gka ugha ftyk jkT; eSa blds }kjk ;g ?kks"k.kk djrk@djrh gwa fd Åij fn, x, fooj.k esjh loksZÙke tkudkjh vkSj fo'okl ds vuqlkj lgh gSaA igys izLrqr fd, esjs dqVqEc ?kks"k.kk iz:i esa ÑI;k blh ds vuqlkj ifjorZu dj fy;k tk,A dqVqEc esa tksMs+ tk jgs lnL;ksa dh ikliksVZ vkdkj dh QksVks layXu gS@gSaA ........................................................................... LFkku % ------------------------------------- chekÑr O;fDr ds gLrk{kj@vaxwBs dk fu'kku rkjh[k % ------------------------------------uke lkQ v{kjks esa--------------------------------------------------fu;kstd ds fooj.k%& uke-------------------------------------------------------------------- fu;kstd&izfrgLrk{kj irk------------------------------------------------------------------- dwV la[;k-----------------------------------------------------------inuke jcM+ dh eksgj lfgr fVIi.kh % ßdqVqEcÞ ls fdlh chekÑr O;fDr ds fuEufyf[kr lHkh vFkok dksbZ ukrsnkj vfHkizsr gSa%& vFkkZr~%& ¼1½ ifr ;k iRuh ¼2½ chekÑr O;fDr ij vkfJr dksbZ /keZt ;k nÙkd vo;Ld vkfJr ckyd] ¼3½ dksbZ ckyd tks chekÑr O;fDr ds miktZuksa ij iw.kZr% vkfJr gS rFkk tks ¼d½ f'k{kk izkIr dj jgk gS] muds 21 o"kZ dh vk;q izkIr dj ysus rd ¼[k½ dksbZ vfookfgr iq=kh] ¼4½ dksbZ ckyd tks fdlh 'kkjhfjd vFkok ekufld vilkekU;rk ;k pksV ds dkj.k f'kfFkykax gS rFkk f'kfFkykaxrk jgus rd chekÑr O;fDr ds miktZuksa ij iw.kZr% vkfJr gS] ¼5½ vkfJr ekrk&firk] ¼C;ksjs gsrq d-jk-ch- vf/kfu;e] 1948 dh /kkjk 2 ds [kaM 11 dks ns[ksa½A ¹ Ñi;k tUe@e`R;q izek.k&i=k dh vuqizekf.kr izfr izLrqr djsaA
