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    ESIC Nomination Form

    Uploaded by

    MohitTantiya
    This document contains an Employees' State Insurance Corporation (ESIC) Form 1 that must be filled out by any new employee to register for insurance coverage. The form requests information about the insured person such as their name, date of birth, address, employer details, and family members to be covered. It also provides instructions for filling out the form correctly and within the required timeframe, as well as an overview of the medical and cash benefits provided by ESIC to insured persons and their dependents.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    ESIC Nomination Form

    Uploaded by

    MohitTantiya
    3K views2 pages
    This document contains an Employees' State Insurance Corporation (ESIC) Form 1 that must be filled out by any new employee to register for insurance coverage. The form requests information about the insured person such as their name, date of birth, address, employer details, and family members to be covered. It also provides instructions for filling out the form correctly and within the required timeframe, as well as an overview of the medical and cash benefits provided by ESIC to insured persons and their dependents.

    Original Description:

    ESIC Description

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    This document contains an Employees' State Insurance Corporation (ESIC) Form 1 that must be filled out by any new employee to register for insurance coverage. The form requests information about the insured person such as their name, date of birth, address, employer details, and family members to be covered. It also provides instructions for filling out the form correctly and within the required timeframe, as well as an overview of the medical and cash benefits provided by ESIC to insured persons and their dependents.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3K views2 pages

    ESIC Nomination Form

    Uploaded by

    MohitTantiya
    This document contains an Employees' State Insurance Corporation (ESIC) Form 1 that must be filled out by any new employee to register for insurance coverage. The form requests information about the insured person such as their name, date of birth, address, employer details, and family members to be covered. It also provides instructions for filling out the form correctly and within the required timeframe, as well as an overview of the medical and cash benefits provided by ESIC to insured persons and their dependents.

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    You are on page 1of 2

    www.esickar.gov.

    in

    EMPLOYEES STATE INSURANCE CORPORATION


    FORM-1
    To be filled in by the employee after reading instructions overleaf. Two Postcard Size photographs are to be
    attached with this form. This form is free of cost.
    (A) INSURED PERSONS PARTICULARS
    1. Insurance No.
    2 Name (in block
    letters)
    Fathers/Husbands
    Name
    Date of Birth
    D
    M
    Y
    Marital
    Status

    M/U/W

    7. Present Address
    ______________________

    6.Sex
    M/F
    8. Permanent Address
    ______________________

    ______________________

    ______________________

    ______________________

    ______________________

    ______________________

    ______________________

    Pin Code

    Pin Code

    e-mail address

    e-mail address

    Branch Office

    Dispensary

    (b) EMPLOYERS PARTICULARS


    Employers Code
    No.
    10. Date of
    Day
    Month
    Year
    Appointment
    11. Name & Address of the Employer
    _____________________________
    _____________________________
    _____________________________
    12. In case of any previous employment
    please fill up the details as under:a) Previous Ins.No.
    b) Emplrs Code No.
    C) Name & address of the Employer

    e-mail address

    (C) 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 Address

    I hereby declare that the particulars given by me are correct to the best of my knowledge and belief. I
    undertake to intimate the Corporation any changes in the membership of my family within 15 days of such
    change.
    Counter signature by the employer
    Signature/T.I.of IP
    Signature with Seal
    (D) FAMILY PARTICULARS OF INSURED PERSON
    Sl.
    No.

    Name

    Date of Birth/ Age


    as on date of
    filling form

    Relationship with
    the Employee

    Whether
    residing with
    him/her?
    Yes
    No

    IfNo, state place of


    Residence

    Town
    State
    1.
    2.
    3.
    4.
    5.
    6.
    ..
    ESI Corporation
    Temporary Identity Card

    (Valid for 3 months from the date of appointment)

    Name
    Ins.No.

    Date of appointment

    Branch Office

    Dispensary

    Space for photograph

    Employers Code No. &


    Address
    Validity:
    Dated:

    1.

    Signature/T.I. of I.P
    Signature of B.M. with Seal
    Submission of Form-1 is governed by regulations 11 & 12 of ESI (General) Regulations, 1950.

    2.

    Family means all or any of the following relatives of an Insured Person namely:-

    (i) A spouse (ii) a minor legitimate or adopted child dependant upon the I.P;(iii) a child who is wholly
    dependant on the earnings of the I.P. and who is (a)receiving education, till he or she attains the age of
    21 years (b)an un married daughter; (iv) a child who is infirm by reason of any physical or mental
    abnormity or injury and is wholly dependant on the earnings of the I.P. so long as the infirmity
    continues; (v) dependant parents (Please see Section 2 clause 11 of the ESI Act 1948 for details).

    3.

    Identity Card is Non-transferable.

    4.

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

    5.

    Submission of false information attracts penal action under Section 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 dependent family members are entitled to full medical care. The
    other benefits in cash include (1) sickness Benefit (2) Temporary Disablement benefit (3) Permanent
    disablement Benefit (4) Dependents benefit and (5) Maternity Benefit (incase of women employees
    subject to fulfillment of contributory conditions.

    8.

    For more details Please Visit website of ESIC at WWW.esic.nic.in or www.esickar.gov.in contact
    Regional office or Branch Office.

    ___________________________________________________________________________________
    FOR BRANCH OFFICE USE ONLY
    1. Date of Allotment of Ins. No. _______________________________________________________
    2. Date of issue of TIC : _____________________________________________________________
    3. Name/ No. of Disp : ______________________________________________________________
    4. Whether reciprocal Medical arrangements involved? If yes, please indicate : __________________

    Signature of Branch Manager

    -------------------------------------------------------------------------------------------------------------------------

    Sl.
    No.

    1
    2
    3
    4
    5
    6

    Name

    Date of Birth/Age
    as on date of
    filling form

    Relationship
    with the
    Employees

    Whether
    residing with
    him/her?
    Yes
    No

    If No, state place


    of Residence
    Town

    State

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