ESIC DECLARATION FORM (INSURED PERSON DETAILS)

Write your employee code

YOUR EMPLOYEE CODE: ___________

Write previous/ existing ESIC number if any

EXISTING ESIC NUMBER (IF ANY): ____________________________

EMPLOYEE NAME:

Write your First Name Write your Middle Name Write your Surname
__________________________________________________________________________________________
FIRST NAME MIDDLE NAME SURNAME

Write your DOB

DATE OF BIRTH: (IN DD/MM/YYYY FORMAT) _____________________________
Write your current marital status
MARITAL STATUS (MARRIED/ UNMARRIED/ WIDOW): ___________________
Write your gender
GENDER (MALE / FEMALE): ______________________
Write your 10 digits Mobile number
MOBILE NUMBER: ______________________________

FATHER'S / HUSBAND'S NAME:

Write your Father/ Write your Father/ Write your Father/
Husband First Name Husband Middle Name Husband Surname
__________________________________________________________________________________________
FIRST NAME MIDDLE NAME SURNAME

PRESENT ADDRESS :
Write your Full Present residential address along with pincode
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

PERMANENT ADDRESS:
Write your Full Permanent residential address along with pincode
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

Details of Nominee u/s 71 of ESI Act 1948 / Rule 56(2) of ESI (Central) Rules, 1950 for payment of Cash benefit in the
event of death.

NAME RELATIONSHIP WITH YOU ADDRESS

Write name of your Write relationship with Write Full residential address of the
nominee your nominee nominee along with pincode

FAMILY PARTICULARS OF INSURED PERSON (Brother & Sister is not covered as Insured Person)

Date of Birth RELATIONSHIP

NAME ADDRESS
[DD/MM/YYYY] WITH YOU
Write all family
members name details
here like father, Write Nominee/s Write relationship Write your Full residential address
mother, spouse & kids. DOB of Nominee i.e., of the nominee along with pincode
Father, Mother,
Do not write your Spouse, etc
Brother and sister
names as they are not
covered as insured
person

Mention any of your BANK ACCOUNT details below (Any Bank details will be considered)

BANK NAME BANK ACCOUNT NUMBER IFSC CODE BANK BRANCH NAME

Write Bank Account Write IFSC code of Write bank branch

Write any Bank Name
number of the same bank the same bank name of the same bank
 GRATUITY FORM FOR APPOINTMENT OF BENEFICIARY (NOMINATION)
The Trustees,
SBICAP SECURITIES LTD
Employees’ Group Gratuity Assurance Scheme

Write your Full Name (First name, Middle Name, Surname)

I, _________________________________________________________________________a Member of SBICAP
SECURITIES LTD Employees' Group Gratuity Scheme, hereby agree to abide by the rules of the said scheme and do
also hereby appoint in terms of Rule 18 of the Rules Beneficiary/ies/ Nominee/s mentioned hereunder to receive the
benefits, payable under the Scheme, in the event of my death before the amount becomes payable has not been paid.
I hereby direct that the benefits under the Scheme, payable in respect of me, shall be paid to the said beneficiaries/
nominees in proportion indicated against their respective names as given below:

Proportion by which
Full name with full Address of Relationship with Date of Birth of gratuity will be
Sr.No
Nominees/Beneficiaries the Employee Nominee/Beneficiaries shared by each
Nominee/Beneficiary
1 Write name of your nominee DD / MMM /YYYY Write the
Write relationship Write DOB of
Write your full residential with your nominee your nominee proportion of
2 DD / MMM /YYYY
address of your nominee the benefits to
along with pincode be given to your
3 DD / MMM /YYYY
nominee. It
should total to
4 DD / MMM /YYYY
100%
5 DD / MMM /YYYY

*In case Nominee is Minor, give Appointee/Guardian details in the below table:

Name of Appointee/ Guardian Relation DOB of Appointee

If your nominee is Minor (less than 18 years old) then fill this columns

 I hereby certify that the person(s) mentioned hereinabove is/are my wife/children/lawfully adopted
child/dependent parents/husband.
 I hereby declare that I have no family, and should I acquire family hereafter, the appointment of
Beneficiary/Nominee should be deemed as cancelled.
 My father/mother/parents/sister ('s)/minor brother(s) is/are not dependent on me. My husband's
father/parents is/are not dependent on me.
 I also declare that this appointment of Beneficiary/ies/Nominee/s made herein shall have the effect of
my revoking the appointment of Beneficiary/ies/Nominee/s made by me earlier.

I give below the particulars about myself:

Write your Full Name (First name, Middle Name, Surname)

1. Full name: _______________________________________________________________
2. Sex: Write your gender Religion: Write your religion Write your Fathers Name
Father Name: _________________
3. Husband Name:- ______________________________________
Write your Husbands name (if female is married)
Write your marital status
4. Marital Status: __________________ whether you are married/ unmarried/ widow
_____________________
5. Date of Birth:-Write
DD/MMM/YYYY
your DOB
 Write your full residential addresses along with pincode
6. Address:- ________________________________________________________________________

___________________________________________________________________________________

Please sign here

Write Date here
Date: DD / MMM /YYYY  Signature of Employee

TWO WITNESSES AND THEIR SIGNATURE

1) Name: Do not write anything

Address:

_______________________________________________________________________________________

2) Name: Do not write anything

Address:
___________________________________________________________________________________________________________

Certified that the above appointment of Beneficiary/Nominee has been signed by Shri/Shrimati
before me after he/she has read the entries/ the entries have been read to him/her by me and
that the said appointment of Beneficiary/Nominee is recorded under the scheme on
Do not write anything
________________________

Do not write anything

SIGNATURE OF TRUSTEE/S
For Self and Co-Trustees of
Place: Do not write anything SBICAP SECURITIES LTD.
Date: Do not write anything Employees’ Group Gratuity
Assurance Scheme.
NOTE:
1) Where an Employee Member has a family at the time of appointing a Beneficiary/Nominee, the nomination
should be made in favor of Member of his family only. Any nomination made by such Employee in favor of
any person not belonging to his family shall be invalid.
2) An appointment of Beneficiary/Nominee made by the Member may be changed at any time, after given
the written notice to the Trustees of his intention to do so. If the nominee predeceases the Member
(Employee), the interest of the nominee shall revert to the Member (Employee) or his estate.
3) The appointment of Beneficiary/Nominee or any change thereof made from time to time shall take effect
to the extent it is valid on the date on which it is received by the Trustees.
4) For the purpose of the Scheme, “Family” means Member’s (Employee’s) spouse, legitimate children/step
children, parents, sisters and minor brothers dependent upon him.
 In case of change in nomination details, please intimate HRD about the same.
 NOMINATION FORM OF GROUP TERM INSURANCE
(Under Section 39 of Insurance Act, 1938)

INSTRUCTIONS:
1. The form must be filled in CAPITAL Letters only
2. If the nomination is in favor of a minor, an appointee/Guardian who is a major must be named in this
form otherwise form would be deemed to be incomplete.

Name of the Employee : Write your Full Name (First name, Middle Name, Surname)

Employee Code : Write your employee code

I, Write your Full Name (First name, Middle Name, Surname) hereby nominate the following person(s) as
my nominee(s) to be the person(s) who will receive the benefit secured by the Group Term Insurance
Policy in the event of unfortunate eventuality.
Proportion by which
Sr. Relationship of Term Insurance (Total
Nominee Name Nominee Date Benefits) will be shared
No. Nominee with
Of Birth by each Nominee (%)
Employee
Write name of your nominee Write DOB of
DD/MMM/YYYY Write relationship Write the proportion
your nominee
DD/MMM/YYYY with your of the benefits to be
nominee given to your
DD/MMM/YYYY
nominee. It should
DD/MMM/YYYY total to 100%
DD/MMM/YYYY

*In case Nominee is Minor, give Appointee/Guardian details

Name of Appointee/ Guardian Relation DOB of Appointee

If your nominee is Minor (less than 18 years old) then fill this columns
 I hereby certify that the person(s) mentioned hereinabove is/are my wife/child/children/lawfully adopted
child/children dependent parents/husband.
 I hereby declare that I have no family, and should I acquire family hereafter, the appointment of Beneficiary/Nominee
should be deemed as cancelled.
 My father/mother/parents/sister('s)/minor brother(s) is/are not dependent on me. My husband's father/parents
is/are not dependent on me.
 I also declare that this appointment of Beneficiary/ies/Nominee/s made herein shall have the effect of my revoking
the appointment of Beneficiary/ies/Nominee/s made by me earlier.
 In case of change in nomination details, please intimate HR Department about the same.

Please sign here

Write Date here
Date: DD / MMM /YYYY  Signature of Employee
 FORM 2 REVISED

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Funds and Employees Pension
Schemes (Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of
the Employees Pension Scheme 1995)
Write Full Name in BLOCK/CAPITAL Letters along with Fathers/
1. Name (IN BLOCK LETTERS) : Husbands Name and Surname _______
Name Father’s / Husband’s Name Surname
Write your DOB in Write PF account number of your
DD/MM/YYYY Format previous organization
2. Date of Birth: 3. PF Account No. _________________________
Mention _____________5.
your Gender Single/Married, etc.
4. *Sex: MALE/FEMALE: Marital Status: ________________________
Write your complete Permanent address along with Pin code
6. Address Permanent / Temporary: ___________
___________

PART – A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the
person(s) mentioned below to receive the amount standing to my credit in the Employees Provident Fund,
in the event of my death.

Total amount or share If the nominee is minor name

Date
Nominee’s of accumulations in and address of the guardian
Name of the Address of
relationship with Provident Funds to be who may receive the amount
Nominee (s) (1) (2) Birth
the member (3) paid to each nominee during the minority of the
(4)
(5) nominee (6)

Write name of Write nominee Mention Write the proportion of If your nominee is Minor
Write address
the family relationship with Nominee the benefits to be given (i.e., less than 18 years
of nominee
member you you i.e., date of to your nominee. The old) then update this
along with pin column
want to nominate Mother, Father, Birth total should not be less
code Wife, Child, etc. or more than 100%

1 *Certified that I have no family as defined in para 2 (g) of the Employees Provident Fund Scheme
1952 and should I acquire a family hereafter the above nomination should be deemed as cancelled.
2. * Certified that my father/mother is/are dependent upon me.

Please Sign here

Strike out whichever is not applicable Signature/or thumb impression of
the subscriber

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 PART – (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive
Widow/Children Pension in the event of my premature death in service.

Sr. No (1) Name & Address of the Family Member (2) Age (3) Relationship with the member (4)

Write the same detail which you

have filled in "Part A" in above page

Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995
and should I acquire a family hereafter I shall furnish Particulars there on in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para
16 2 (a) (i) & (ii) in the event of my death without leaving any eligible family member for receiving pension.
Name and Address of the nominee Date of Birth Relationship with member

Write the same detail which you

have filled in "Part A" in above page

Date Mention Date here

Please sign here

Signature or thumb impression
of the subscriber

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 CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed / thumb impressed before me
by Shri / Smt./ Miss Write your Full Name
_____________________________________________________employed
in my establishment after he/she has read the entries / the entries have been read over to him/her by me
and got confirmed by him/her

DO NOT SIGN HERE

Date: _________________ Signature of the employer or other

authorised officer of the establishment

Name & address of the Factory /Establishment:

Do not write anything here

Place:
Date:

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 EMPLOYEES PROVIDENT FUND ORGANIZATION
New Form No.11- Declaration Form (To
Employees provident funds scheme, 1952 be retained by the employer for future reference)
(paragraph 34 & 57) & Employees pension
scheme 1995 (paragraph 24)
Emp Code: Write your employee code

Company: Write SBICAP Securities Limited

Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 end /of EPS1995 is applicable

1 Name of the member Write your Full Name

Father’s Name ( ) Spouse’s Name ( )
2 <==Tick on relevant option Write your Father's/ Spouse's Name
(Please Tick Whichever Is Applicable)
3 Date of Birth (DD/MM/YYYY) Write your DOB

4 Gender: ( male / Female /Transgender ) <==Tick on relevant option Mention your Gender

5 Marital Status (married /Unmarried /widow/divorce) <==Tick on Mention if you are married/ single/ etc.
relevant option
(a) Email ID: Mention your Personal email ID
6
(b) Mobile NO: and your Mobile Number

7 Whether earlier a member of Employees ‘provident Fund Scheme 1952 Mention (YES/ NO)

8 Whether earlier a member of Employees ‘Pension Scheme ,1995 Mention (YES/ NO)

If response to any or both of (7) & (8) above is yes. MANDATORY FILL UP THE (COLUMN 9)
Mention your UAN number of previous
a) Universal Account Number(UAN) organization

b) Previous PF a/c No Mention your PF number of previous

organization
9
c)Date of exit from previous employment (DD/MM/YYY) Write your Last working date in your
previous organization
d) Scheme Certificate No (if Issued )

e)Pension Payment Order (PPO)No (if Issued)

a)International Worker:

b) If Yes , State Country Of Origin (India /Name of Other Country)

10
c) Passport No Mention your Passport Number, if any

d) Validity Of Passport (DD/MM/YYY) to(DD/MM/YYY) Mention Validity Period of your Passport

KYC Details: (attach Self attested copies of following KYCs) **

a)Bank Account No .& IFS code Write your Bank Account No & IFSC Code
11
b) AADHAR Number (12 Digit) Mention your Aadhar Number

c)Permanent Account Number (PAN),If available Mention your PAN number

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UNDERTAKING

 Certified that the Particulars are true to the best of my Knowledge

 I authorize EPFO to use my Aadhar for verification / e KYC purpose for service delivery
 Kindly transfer the funds and service details, if applicable, from the previous PF account as declared
above to the present P.F Account (the transfer would be possible only if the identified KYC details
approved by previous employer has been verified by present employer).
 In case of changes In above details the same Will be intimate to employer at the earliest date:

Please sign here

Place: Write your location Signature of Member

DECLARATION BY PRESENT EMPLOYER

A) The member Mr./Ms./Mrs DO NOT FILL has joined on DO
……………….. NOT FILL and has been allotted PF
…………….
Number……………………………….
DO NOT FILL

B) In case person was earlier not a member of EPF Scheme ,1952 and EPS,1995
 (Post allotment of UAN ) The UAN Allotted for the member is…………..
DO NOT FILL

 Please tick the Appropriate Option:

 The KYC details of the above member in the UAN database
 Have not been uploaded
 Have been uploaded but not approved
 Have been uploaded and approved with DSC
C) In case the person was earlier a member of EPF Scheme ,1952 and EPS, 1995:
 The above PF account number /UAN of the member as mentioned in (a) above has been tagged
with his /her UAN/previous member ID as declared by member
 Please Tick the Appropriate Option
 The KYC details of the above member in the UAN database have been approved with digital
signature Certificate and transfer request has been generated on portal.
 As the DSC of establishment are not registered With EPFO the member has been informed to
file physical claim (Form13) for transfer of funds from his previous establishment.

DO NOT SIGN HERE

Date Signature of Employer With
seal of Establishment

20