¡ ɨÉÇ-1 FORM - I PÉÉ ¹ÉhÉÉ {ÉjÉ DECLARATION FORM (A)INSURED PERSON'S PARTICULARS (B)EMPLOYER'S PARTICULARS 9. Employer's Code Number 1. Insurance Number 10. Date of appointment Day Month Year 2. Name (in block letters) 11. Name & Address of the Employer 3.Father's/Husband's Name 4. Date of Birth 5.Marital Status (? the appropriate box) Married Day Month Year Unmarried Widower 6. Sex (? the appropriate box) Male PIN Female Telephone Transgender Mobile 7.Present Address E-mail Address Website 12. Previous employment, if any Previous Insurance Number PIN Employer Code Number Telephone Mobile Name & address of the Employer E-mail Address 8.Permanent Address PIN BRANCH OFFICE DISPENSARY (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. Name Relationship Address, Mobile & Email Coimbatore Sub-Region Page 1 of 2 (D) FAMILY * PARTICULARS OF INSURED PERSON Sl. No. Name Date of Birth/Age as on date of filling form Relationship with the Employee Whether residing with him/her? If 'No', state place of Residence Yes No Town State 1. 2. 3. 4. 5. 6. 7. 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. Counter signature by the employer with seal Signature/T.I. of IP For office use - Authentication by ESIC Branch Manager Seal Signature * Family, as defined under Section 2(11) of the ESI Act, 1948, includes the following persons:- 1) Spouse of the insured person (Wife or Husband) 2) Minor dependant son (legitimate or adopted) 3) Minor dependant daughter (legitimate or adopted) 4) Son or daughter till he or she attains 21 years of age, if wholly dependent and receiving education 5) Daughter, if wholly dependent and unmarried 6) Infirm child, if wholly dependant 7) Dependant parents Coimbatore Sub-Region Page 2 of 2
