?kks"k.kk i=k DECLARATION FORM QkeZ&1@Form-1 ?kks"k.kk i=k deZpkjh }kjk Hkjk tk,xkA QkeZ ds LkkFk iksLVdkMZ vkdkj ds nks QksVksxzkQ Hkh yxk, tkus pkfg,A QkeZ Hkjus ls igys ihB i`"B ij nh xbZ fgnk;rksa dks Hkyh&Hkkafr i<+ ysuk pkfg,A ;g QkeZ fu%'kqYd gSA To be filled by employee after reading instruction overleaf. Two Postcard Size phtographs to be attached with the form. This form is free of cost. ¼d½ chekÑr O;fDr ds fooj.k ¼[k½ fu;kstd ds fooj.k (A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS eSa ,rn~}kjk ?kks"k.kk djrk@djrh gwa fd esjs }kjk izLrqr fd, x, fooj.k esjh tkudkjh vkSj fo'okl ds vuqlkj lgh gSA eSa vius ifjokj ds lnL;ksa esa gq, ifjorZu dh lwpuk 15 fnu ds Hkhrj izLrqr djus dk opu Hkh nsrk gwa@nsrh gwaA I hereby decalare 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. fu;kstd ds izfrgLrk{kj Counter signature by the employer chekÑr O;fDr ds gLrk{kj@vaxwBk fu'kku Signature /T.I.of IP. lhy lfgr gLrk{kj Signature with seal ¼?k½ chekÑr O;fDr ds ifjtuksa dk fooj.k (D) Family Particulars of Insured person Ø-la uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha rks vkokl SI. No. Name dks vk;q@tUe&rkjh[k Relationship with the jgs gSa\ crk,a dk LFkku n'kkZ,a Date of Birth/Age as on Employee Whether residing If' No' state Place of date of filling form with him/her. Residence gk¡@Yes ugha@No dLck@Town jkT;@State d-jk-ch- fuxe vLFkk;h igpku i=k ¼fu;qfDr dh rkjh[k ls 3 eghus rd oS/k½ ESI Corporation Temporary Identity Card (Valid for 3 month from the date of appointment) uke@Name chek la[;k@Ins. No. fu;qfDr dh rkjh[k@Date of appointment 'kk[kk dk;kZy; Branch Office vkS"k/kky; Dispensary QksVks ds fy, LFkku (Space for photograph) fu;kstd dh dwV la[;k o irk Employer's Code No. & Address oS/krk Validity rkjh[k chekÑr O;fDr ds gLrk{kj@vaxwBs dk fu'kku lhy lfgr 'kk[kk izca/kd ds gLrk{kj Dated Signature/T.I. of I.P. Signature of B.M. with seal vuqns'k INSTRUCTIONS 1 QkeZ&1 dk izs"k.k d-jk-ch- ¼lk/kkj.k½ fofu;e] 1950 ds fofu;e 11 o 12 ds varxZr fofu;fer fd;k tkrk gSA Submission of Form-I is governed by regulation 11 & 12 of ESI (General) Regulations, 1950 2 ßdqVqEcÞ ls fdlh chekÑr O;fDr ds fuEufyf[kr lHkh vFkok dksbZ ukrsnkj vfHkizsr gS%& vFkkZr~%& ¼1½ fookfgrh 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"Z 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 "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 physcial 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 igpku&i=k vgLrkUrj.kh; gSA Identity Card is Non-Transferable. 4 igpku&i=k ds xqe gksus dh fLFkfr esa fu;kstd@'kk[kk izca/kd dks rRdky lwfpr fd;k tk,A Loss of Identity Card be reported to Employer/Branch Manager immediately. 5 fdlh izdkj dh xyr lwpuk nsus dh fLFkfr esa d-jk-ch- vf/kfu;e] 1948 dh /kkjk&84 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA Submission of false information attracts penal action Under Section 84 of ESI Act. 1948. 6 ubZ fu;qfDr dh fLFkfr esa Hkyh&Hkkafr Hkjk gqvk ;g QkeZ fu;qfDr ds nl fnu ds Hkhrj lacaf/kr 'kk[kk dk;kZy; esa vo'; gh izLrqr fd;k tkuk pkfg,A foyEc dh fLFkfr esa fu;kstd ds fo#) /kkjk&85 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA 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 chekÑr O;fDr gksus ds ukrs vki o vkids ifjokj ds vkfJrtu fpfdRlk fgrykHk izkIr dj ldsaxsA vU; udn fgrykHk gSa] ¼1½ chekjh fgrykHk ¼2½ vLFkk;h viaxrk fgrykHk ¼3½ LFkk;h viaxrk fgrykHk ¼4½ vkfJrtu fgrykHk ¼5½ izlwfr fgrykHk ¼efgyk deZpkjh ds fy,½A As an insured person you and your dependant family membes are entitled to full medical care. The other benefits in cash include (1) Sickness Benefit (2) Temporary Disablement benefit (3) Permanent disablement Benefit (4) Dependants benefit and (5) Maternity Benefit (in case of woman employees) subject of fulfillment of contributory cnditions. 8 vf/kd tkudkjh ds fy;s Ñi;k fuxe ds osclkbV dks nsa[ksa ;k 'kk[kk dk;kZy; ;k {ks=kh; dk;kZy; ls laidZ djsaA For more details please contact website of ESIC at www. esic.org. in. or contact Regional Office or Branch Office. dsoy 'kk[kk dk;kZy; esa iz;ksx gsrq For Branch Office Use only 1 chek la[;k vkoaVu dh rkjh[k % Date of allotment of Ins. No. : 2- vLFkk;h igpku i=k tkjh djus dh rkjh[k % Date of Issue of T.I.C. : 3 vkS"k/kky; dk uke@la[;k % Name /No. of Dispensary : 4 D;k vU;ksU; fpfdRlk O;oLFkk miyC/k gS\ ;fn gkaa] rks mYys[k djsa % Whether reciprocal Medical arrangements involved. if yes, please indicate : 'kk[kk izcU/kd ds gLrk{kj Signature of Branch Manager Ø-la-SI. No. uke Name QkeZ Hkjus dh rkjh[k dks vk;q@tUe&rkjh[k Date of Birth/Age as on date of filling form deZpkjh ds lkFk ukrsnkjh Relationship with the Employee D;k muds lkFk jg jgs gSa\ crk,a Whether residing with him/her. ;fn ugha] rks vkokl dk LFkku n'kkZ,a If' No, state Place of Residence gk¡@Yes ugha@No dLck@Town jkT;@State
