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

FORM 1A: Family Declaration Form

[Regulation 15A]

Name of the insured person ……………………………………

Insurance Number ……………………………………………….

Sl. No.

Name

Date of birth

Relationship with insured person

*Whether residing with him/her or not

 

 

 

 

 

*My Family Declaration Form may kindly be corrected accordingly.

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

……………………………………………….

Signature/Thumb-impression of the insured person

Date………………………….

Countersigned …………………………………

Date ……………………………………….

Designation ………………………………..

Name, address and code no. of employer……………………………………………………………

Note: According to section 2, clause (1 1) 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) minor legitimate or adopted child dependent upon the IP; (iii) a child who is wholly dependent on the earnings 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.

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