Form 1 – EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS,1950

FORM 1: Declaration Form

[Regulations 11 and 12]

Serial No. in return of                                                                                  46[* * *]

Declaration in Form No. 3

(To be filled in only if the employee has not been insured earlier)

Insurance No………………………..                  Employer’s Code No ……………………

1. Name (in block capitals) …………………………………………

2. Father’s/husband’s name …………………………………………

3. Present address ………………………………………..

4. Permanent address …………………………………………….

5. Local office …………………………………………………….

6. Sex…………………………………..

7. Marital status (state whether bachelor, spinster, married, widow or widower) ………………

8. Age ……………….

9. Year of birth ……………………………………

10. Dispensary …………………………..

11. Particulars of employment:

(a) Date of appointment …………………………………..

          (b) Whether employed directly/through contractor ……………………………

(c) Department ………………………………………

(d) Nature of work ………………………………………

12. Nomination under section 50(2) (in case of females only) and 71 of the Employees’ State Insurance Act, 1948 for payment of any benefit that may be due as specified in these sections, in the event of the death of insured person:

(a) Name of nominee …………………………………………………………….

(b) Age ……………………………

(c) Father’s/husband’s name ………………………………………….

(d) Relationship of nominee with the insured person cut here……………..cut here……………………………………………

(e) Address ………………………………………………

TEMPORARY IDENTIFICATION CERTIFICATE

(Valid for 13 weeks from the date of appointment)

Insurance No……………………………………………

Name of the insured person……………………………. Sex………………………………….. Age………………

Name, address and Code No. of the employer ……………………………………………………………………………….

………………………………………………………………………………….. 13. Particulars of member of family:

Sl. No.

Name

Date of birth

Relationship with insured person

Whether

residing with him/her or not

 

 

 

 

 

14[Note: According to section 2, clause (11) of the Employees’ State Insurance Act, 1948 “family” means all or any of the following relatives of an insured person, namely, (i) a spouse; (ii) a minor legitimate or adopted child dependent upon the IP; (iii) a child who is w
holly dependent on the earning of the IP 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 dependent on the earnings of the IP, so long as the infirmity continues; (v) dependent parents.]

    I affirm that I have NOT been previously insured under the Act and no identity card has been issued to me.

    I hereby declare that the above particulars have been given by me and are correct to the best of my knowledge and belief. I also undertake to intimate to the Corporation any change in the membership of my family within 15 days of such change having occurred.

Place………………………………

Date of signing the Form …………………………………………

……………………………………………….

Signature or thumb-impression

of the employee

…………………………………………….

Counter signature of employer

Designation……………………………

Name and address of the employer………………………………..

………………………………………..cut here………………………………………………………………………………

RECEIPT OF IDENTITY CARD

Received the Identity Card bearing Insurance

No. as overleaf ……………………………………

…………………………………………

Date Signature or thumb-impression

of the insured person

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