qtqUTT qT DECLARATION FORM qtd-tzForm-t
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S To be filled by employee alter reading instruction overleaf. Two Postcard Size phtographs to be attached
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lorm. This form is free of cost.
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(A) TNSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS
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Employer's Code No.
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Name in block letters Date of Appointment Day Month Year
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ln case of any previous employment please fill up the details as under.
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(a) Previous Ins. No.
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(b) Employer's Code
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Brach Office Dispensary
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(c) Details of Nominee u/s 71 of ESlAct
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1948/Rule-56(2)of ESI (central) Rules, '1950 for payment of cash benefit in the event of death'
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I hereby decalare that the particulars given by me are correct to the best ol my knowledge and belief. I undertake
to intimate the corporation any
changes in the membership of my family within 15 days of such change.
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Signature /T.l.of lP.
Counter signature bY the emPloYer
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Signature with seal
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(D) Family Particulars of Insured person
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Date of Birth/Age as on Employee Whether residing lf' No'state Place of
date of fillinq form with him/her. Residence
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(Valid for 3 month from the
ESI Corporation Temporary ldentity Card c
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INSTRUCTIONS
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Submission of Form-l is governed by regulation 11 & 12 of ESI (General) Regulations, 1950
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"Family" means all or any of the following relatives of an lnsured Person namely:-
(i) a spouse (ii) a minor legitimate or adopted child dependant upon the l.P.; (iii) a child who is wholly dependant on the
earnings of the l.P. 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 physcial or mental abnormality or injury and is wholly dependant on the earnings
of the l.P. so long as the infirmity continues; (v) dependant parents (Please see Section 2 clause '11 of the ESI Act 1948 for
details.
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ldentity Card is Non-Transferable.
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Loss of ldentity Card be reported to Employer/Branch Manager immediately.
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Submission of false information attracts penal action Under Section 84 of ESI Act. 1948.
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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.
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As an insured person you and your dependant family membes are entitled to full medical care. The other benefits in cash
include (1) Sickness Benefit (2) Temporary Disablement benefit (3) Permanent disablement Benefit (4) Dependants benefit
and (5) Maternity Benefit (in case of woman employees) subject of fulfillment of contributory cnditions.
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For more details please contact website of ESIC at www. esic.org. in. or contact Regional Office or Branch Office.
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. For Branch Office Use only
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Date of allotment of Ins. No. :
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Date of lssue of T.l.C. :
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Name /No. of Dispensary :
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Whether reciprocal Medical arrangements involved. if yes, please indicate :
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Signature of Branch Manager
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date of fillino form with him/her. Residence
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