Rules and Regulations of India

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Form 4a – EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS,1950

 FORM 4A : Family Identity Card

[Regulation 95A]

Insurance No…………………………………..

Name of insured person…………………………………………..

Sex…………………………….

Son/daughter/wife of………………………………………….

Address…………………………………………………………………………………………………………………………

Dispensary…………………………………………………………………………………

PARTICULARS OF MEMBERS OF FAMILY

Sl. No.

Name

Date of birth

Relationship with the insured person

Identification marks

1

 

 

 

 

2

 

 

 

 

Prepared by:

Signature or thumb-impression

of the insured person

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