FORM 1B: Changes in Family Declaration Form
[Regulation 15B]
Name of the insured person………………………………………
Insurance No …………………………………………….
I hereby declare that the person/persons whose particulars are given below has / have now become / ceased to be members of my family ..
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Sl. No. |
Name |
Date of birth |
Relationship with insured person |
* Whether residing with him/her or not |
Reasons for change |
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I hereby declare that the particulars given above are true to the best of my knowledge and belief.
Signature/thumb impression of the insured person
Date…………………………..
Countersigned …………………………..
Date ………………………………………….
Designation …………………………………..
Name, address and code no. of the employer…………………………………………………………….
14Note: 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, (i) a spouse; (ii) a 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 earning of the IP, so long as the infirmity continues; (v) dependent parents.]
