EMPLOYEES STATE INSURANCE CORPORATION

PHOTO IDENTITY-CARD FORM

Insurunce No.
Emp. Code No.
Name
(in block capital)
Gj|uDg YA SHNuKuMA R A|Ho

Father's YA NnsTmA As AHU

husband's Name
Present Address - o8
KANcHLh vLLAD
Pin Code
SRkaEAANDHRAPKADESHI
Local Office
Sex 1 Dispensary
Marital Status (state, whether, Bachelor, Spinster, Marrie, Widow or Widower) UNMARRT ED
DD MM Y Y YY
Age2 S Year OfBirth26 h9
Particulars ofemployment
(a) Date of appointment H-223
(b) Whether employed directly Through Contractor
(C) Department

(d) Nature of Work

(e) Name ofNominee

()
GlDoKA
Details offamily members
NA2As THASA
S.No. Name
Date Relationshíp Whether residing
of with insured with him/ her
Birth person or not

1. GNARASLMA SAHU oloz|1434fAN HER

2. G KUMAL 1 olol 943 MoHER
3. 6 CHAADHUAlu 2so420otReoHER No
4
5.
6.

Signature or thumb impression of Verified by Employer

the insured person (Signature with Seal)

Supplicd by: Gupta Book Centre, G-6/ISkyline House, 85, Nchru Place, New Dclhi - 110019 Phones:26449929,262 19041
Price Rc. l/- each & S.T. Extra.
 DECLARATION FORM FORM 1
To be filled by cmployce afler rcading Instruction overleaf. Two Postcard Size photographs to be attached with the form.
(A)INSURED PERSON'S
1. Insurancc No.
PARTICULARS (B) EMPLOYER'S PARTICULARS
9. Employer's Code No.
2. Namc
(in block letters) UlYA 10. Date of Appointment Day Month Year
3. Father's
Husband's Name
VHNUKUMARSAHu o4| 1 2 23
1. Name & Address of the Employer
4. Date of
Day Month Year
Birth S. Murital
Slatus
MLN
1445 206 | 5 4 6. Sex
7. Present Address
8. Permanent Address
12. In casc of any prcvious cmployment plcase fill up the details as under
#ND-yo, S VenktDrno(06, Mineon,
a) Previous Ins. No.
b) Employers Code No.
Andha Pradeh c) Name & Address of the
Employcr
Pin Code S|8 o6 Pin Code g 322
Tel. No. l e-mail address Tel. No.le-mail address
b
Branch Tel. No. le-mail address
Office Dispensary
C. Details of Nomince /s 71 of E.S.I. Act,
1948/ Rule-56 (2) of ESI (Central) Rules 1950 for payment of cash benefit
Name
in the event of death.
Relationship AddresS
UDÍyA NARASTNHASHU {ATHEL -108) t.2asysloh m,kanelili, fAndgde
hereby declare that the particulars given by me are correct to the best of my
I
changes in the membership of my family within 15 days of such knowledge and belief. Iundertake to intimate the Corporation any
change.

Counter Signature by the employer Signature

with Seal
(D)FAMILY PARTICULARS OF INSURED PERSON Signature/T.I. ofIP
S Name Date of Birth/ Age as on
No.
date of filling form
Relationship with Whether residing with If no, State place of
the Employee him/her ,say Residence
Yes No Town State
G-NAR ASTHO SAH
2

l2so4 |200|BRTHEL

ESICorporation (Temporary Identity Card) (valid for 3 months from the

Name date of appointment)

Ins. No. Datc of

appointment
Branch Office
Dispensary (Space for photograph)
Employer's Code No. &
Address

Validity : Dated: Signature/Tl. of LP. Signature of B.M. with seal

GUPTA BOOK CENTRE, Skyline House, 85, Nehru Place,N. D.-19 Ph.:
26449929,26219041 Price Rs. l/- cach & Dvat Extra.
 INSTRUCTIONS

1 Submission of Forn-l is govermed by regulations 11 & 12 of ESI(General) Regulations, 1950.

"Family" mcans allor any of the following rclatives ofan Insurcd Person namcly:
() aspouse (ii) a minor legitimate or adopted child dependant upon the 1.P.; (iii) a child who is wholly dependant on
the carmings of the I.P. and who is (a)receiving cducation, till he or she attains the age of 21 ycars (b) an unmarricd
daughter ; (iv) achild who is infim by rcason of any physical or mcntal abnormality or injury and is wholly dependant
on the carmings of the 1.P. so long as the infirmity continues; (v) dependant parents (Plcase sce Section 2 clause I lof
the ESI Act, 1948for details).

3. Identity Card is Non-Transferable.

4. Loss of ldentity Card be reported to Employer/ Branch Manager immediately.

Submission of false information attracts penal action under Scction 84 of ESI Act, 1948.
6 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.
7
As an insured person you and your dependant family members are entitld to full medical care from today itself. The
other benefits in cash include (I)Sickness Benefit (2)Temporary Disablement benefit (3) Permanent disablement Benefit
(4) Dependents Benefit and (5) Maternity Benefit (in case of women employees) subject to fulfillment of contributory
conditions.

For More details please contact website of ESIC at www.esic.org. in or contact Regional Office or Branch Office.

(For Branch Oflice Use Only)

1. Date of allotment of Ins, No.

2. Date of issue of TJ.C.

3. Name/ No. of Disp.

4. Whether reciprocal Medical arrangements involved. if yes, please

indicate

Signature of Branch Manager

UMOJ. ON
Kes Jauy
JWEN IS
 THE PAYMENT OF GRATUITY (CENTRAL) RULES, 1972
FORMF
[Sce sub-rule (1) of Rule 6]
To
Nomination

1. Shri/Shrimati/Kumanvol yA HANEUMAR AUwhose particulars are given in the

statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable
after my death as also the gratuity standing to my credit in the
amount has become payable or having become payable event of my death before that
has not been paid and direct that the said
amount of gratuity shallbe paid in proportion indicated against the
name(s) of the nominee(s).
2. Ihereby certify that the person(s)
mentioned is lare member(s) of my family within the meaning of
clause (h) of Section 2 of the Payment of Gratuity Act, 1972.
3. Thereby declare that I have no family within the
meaning of clause(h) of section 2 of the said Act.
4. (a) My
father/motherlparents islare not dependent on me.
(b) My husband's
fatherlmotheriparents islare not dependent on my husband.
5 Ihave excluded my husband from my
family by a
Controlling Authority in terms of the proviso to clause(h)notice dated the
of Section 2of the said Act.
to the

6 Nomination made herein invalidates my previous nomination.

NOMINEE(S)
Name in full with
Full address of Relationship
with the
Age of nominee
Proportion by
Nominee (s) which the gratuity
employee will be shared

G NARA STNHA CAHU

|H06, mai nvadd,
ICandali (in,pst hand) FAJHER 1o0.
Snkslculo Cdit,
 THE PAYMENT OF GRATUITY (CENTRAL RULES, 1972 )

STATEMENT
1. Namc of employce in full:
2 Sex
3. Religion
:MALE
HîNDV
4
Whether unnmarried/married'widow/widower : UN MPRIED
S. Department / Branch/ Section where employed : CuITD ME n FocTAG OE 2 A6NS
6 Post held with Ticket or Serial No., if any:
7 Date of appointment :
Permanent address:
Village... KANLHILD Thana.. .Sub-division,
KMCHS..Distriet. SiKARLAM Stuate.Andhedel
Post office.............

Place
Date:
orinression
Signaturd/
hopoyee
DECLARATION BY WITNESSES

Nomination signed / thumb impressed before me

Name in full and full address of witness Signature of witness
1.

2.

Place

Date

Certilicate by the Employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any.

Signature of the employer / officer authorized

Date Designation
Name and address of the establishment or rubber stamp thereof
Acknowledgement by the Employee
Received the duplicate copy of nomination in Form F fled by me and duly certified by the
employer

Date :.
Signa mploye
Note : Strike out the words / paragraphs not applicable.
 FORM - 2( Revised)

NOMINATION AND DECLARATION FORM

FOR EXEMPTED/ UNEXEMPTED ESTABLISHMENTS
Drlaration and Nomination Form Under the Employce's Provident Funds &e Employees' Pension Scheme
(l'aragraph 33 &61 (1) of the Employees' Provident Fund Scheme, 1952 &Paragraph 18 of the Employees's Pension Scheme, 1995)

1 Name ( In Block Letters)

GUDYA NCSHNUkUMAR ShHU
2 Father's / Husband's Name : GuofA NARATMHACAHU
3 Date of Birth

4 Sex
MALE
5 Marital Status UN M
ARîED
Account Number

7 Address Permanent
I1O8,Maimmood, Icaneliu(i),sitalon Andhredes
Temporary
Date of Joining Beresboo6]
EPF

EPS

PART - A (EPF)
Ihere by nominate the person(s) / cancel the nomination
made by me
receive the amount standing to my credit in the Employees' Provident Fund,previously and person(s) mentioned below to
in the event of my death.
Name & Address of the Nominee's relationship Date of Total amount of share of if the nominee is minor name &
Nominee/ Nominees with the member Birth accumalation in provident address & relationship of the
fund to be paid to cach nominee guardian who may recive the amount
1 2 3 4 5
GNARALSN HA
HoS, moinvod,
FHeK"
kanidi,sátetuan,
1 Certified that Ihave no family as defined in para 2 (g) of the Employee's Provident
acquire a family hereafter the above nomination should be deemed as cancelled Fund Scheme 1952 and should I
2 Certified that my father / mother is/ are depended upon me.
3 Unmarried members in the absence of dependent parents may nominate hny oer
person to receive the shares

Note: A Fresh nomination shall be made by the member on

his/her marriage and any nomination made before such
marriage shall be deemed to be invalid
Signature or thumnpression of the Subscriber
 PART - B(EPS)

Ihereby furnish below particulars of the members of my family who would be eligible to receive widow/children pension
in the event of my death

SNo Name of tuhe Family Members Address Date of Birth Relationship

16NARASTMHA CAHU
2 KyMARI ot |il3 MeTHE Q
3G CHAploH cAHU 2s]o|1ool RRoHEK
4

Certified that Ihave no family as defined in para 2 (vij) of the Employee's Pension Scheme 1995 and should I acquire a
family hereafter the above nomination should be deemed as cancelled

Ihereby nominate the following person for receiving the monthly widow pension (admisible under para 16(2) (8) () &
(ü) in the event of my death with out leaving any eligible family member for receiving pension.

Name & Address of the Nominee Date of Birth Relationship with themember
G NheA MIA SAtu,

Date:
X

Signature / Thumb mpressionof the subscriber

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before shri/Smt/ Kum
employed in my establishment after he/she has read the entry/entries have been read over to
|him/her by me and got confirmed by him/her.

Place:
Date:
Signature of the emplover

Name & Address of the Establ1sment