‘womw.esicmaharashtra.gov.in rit FORM- UIT TH DECLARATION FORM * sive fe er seo I ed Bare rans ae ACME Ao a I eh @ HE Kes. es yes oe oh a FR wh Tey a RE A eo RR To be fied in by the employe ale tescing instructions overeat. Two Postcard Size photographs are to be aachod wi is form. Thi form few of cost. (ee) tore ets or eer (2) Petros Rarer JANSURED PERSON PARTICULARS )EUPLOYER S PARTICULARS 1.4 ensure No. 8: ers ge He Employers Code No 2. aa (we aed a) TR TS Te, |S ref lock ters) Am an 9 Appotiment oo] Yaar Than oar 5 Ti. Bias ia ar wae & Addiess ofthe Employer Fonts Nore Shiv Kumar a TAs TBAT PB fm [yt | Fiat y | Steve feel See ra 7: i wayPresert Adress '. si Wal Permanent Aes TE ai wa For oP Fw pen la Re Sy Emmet nee | | Incase of any prevous employment pease fll up the detals user Fane ee "24a Gy PO ca as under:- pl ey ay et aa wa 8) Provious ins. No ayaa ga eae ‘ae ) Empirs. Code No pncove C13 BT ToT2) | rcoce CISTSTNTO12 | | fairass wrame nie 6) Name & address of te Employer th seep ta eye eet veel adress ‘ia wore aie ‘ct o/s taye-mall adress Branch Otice Dispensary (2) a4 Fh vo Reson fe oA, 1048 am Tip mh, (ta) Pw 1000 & Pn G2) a BAT (C) Detals of Nomingo ls 74 of ES Act 1948/Rule 562) of ESI (Conta Rules, 1960 for payment of cash Benet in the event of death si iNiome ‘e/Relatonstip vandross Manju Mother [125 B3 Bhima Devi Colony, Pinjore, Dist. Panchkula, 134102 {Tape em 6 AY ee P e fe wewot ae Ra aga wh EA al aa wee Ay Ra qe 15 Fe oe Hoge are a eee tga ¢ | "hereby declare tha he parularsghen by me ae corte fo thebestof my knowedge and bebe | undertake fo timate the Corporation any changes inthe membership of my family wn 1 daye of uch TY bt Pane hm Courter signature byte employer “ ° “ dop( weenerefSy Pree Signatuert | of evant Signature wih seal (3) npn woe oe Aa PARTE OF MBURED PERSON et ™ owe aT aT og] RT we | a a ET ERT wa ww SA SI No Name Date ot Brage as on | Relatorship wih the | “Whether residing | INO, state pace of Residence ate of ling form Empl wn wher? 7 itew cee ‘i Tres | wtiNo | we aeTToWm wasiate z = + 5 6. 7. & . seed age (Cr AS a ee) ESI Corporation (valid for 3 months from the date of appointment) Temporary idenity Card Name ar wane, No. 7 THR/Date of appointment " oe ee sa seed gu Rare wr het -_ : (Space for photograph) Branch Office Dispensary age daw Employers Code No. & Address ‘due: Veliiy: or - ts Wan Dated: 1.122023 i Sie nits Wen setae wus & eI SignatureiT! of LP Signature of &.M. ath seatwnwnw.esicmaharashtra.gov.in oye INSTRUCTIONS sort a Shoo wath (aero) fePramrf-1950 & FAP 11 a 12% ara fra frat oem #1 ‘Submission of Form is governed by regulations 11 & 12 of ESI (General)Regulations, 1950. ‘ua wr ef & (1) wRyoh (2) Alara af a se ne sae Aer sar ah FY ser epee Gt (3) 21 ad aA ony cw arg ea we anPbt Aer sreraT aig Are Gar eee wea ay Aer art ae eT et (4) 7B ae pe afin ara ae Fake een ear (6) sn TAFT wa. TaN aA eT? are cuneate sie wariia uaa fafticar tata & ewer €1 “Family” means all or any of the following relatives of an Insured Person namely:- (i) a spouse (i) a minor legitimate or adopted child dependant upon the LP; il) @ child who is wholly dependant on the eamings of the IP. and who is (a) receiving education, tl 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). reuse Identity Card is Non-transferable. ‘carne a et FRR A Preteen araor setae wh opr ee Prat ay | Loss of identity Card be reported to Employer/Branch Manager immediately. fet rare af mart Yor 2A a RUA A wer, sifFTM-1948 aH OTA-84 % ae arp artardt a TTA tl ‘Submission of false information attracts penal action under Section 84 of ESI Act, 1948. ag Pro FRAY A rah er go aE oT Fay BS er Ror ae aR wrt rafera A aT ag par aret aeg ae oA RE A Frere fa ATT 86 ee TA aah oH a BL ‘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. ‘tert catty steeret wel ph aoe re Pret Aer ser ae arbor (1) ata) Berane (2) rer seb ree (3) seater frets (4) Pen Ht Fert (5) eh fre awe Fe) | ‘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 fulfilment of contributory conditions. crs rer) feral Fro & derge Www.esic.org. in ay tel ar err arate ar Peer eran rr wt For more details please visit website of ESIC at www.esic.org.in or contact Regional office or Branch Office, ‘ee or ree Wn bg FOR BRANCH OFFICE USE ONLY 1, Gone aren of te Date of Allotment of Ins. No. 2. an me re a eter Date of issue of TIC 3, ator a area Name/No, of Dis, 4, ae sen foe one ser. a ste Whether reciprocal Medical arrangements involved? If yes, please indicate: ea He ‘Signature of Sranch Manager a cI wid da aoy | ahaha watmaat ata ae ea S1No. Name Date of Bintwvage as on | Relationship wit the | Whether resicing No, state place of Residence date of fling form Employee. wth hier? = ae me ne Gives | seiNo | ae wayTown waite