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    Employees' State Insurance Corporation: Addition/ Deletion in Family Declaration Form

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    nasir ahmed
    This document is a family declaration form from the Employees' State Insurance Corporation for adding or removing members from an insured person's family. It contains fields to provide details of the family member being added/removed such as name, date of birth, relationship to insured person, reason for change, and whether they reside with the insured. The insured person must declare that the information provided is true and submit photographs of any added family members. The employer must countersign the form after verifying the details.

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    Employees' State Insurance Corporation: Addition/ Deletion in Family Declaration Form

    Uploaded by

    nasir ahmed
    413 views1 page
    This document is a family declaration form from the Employees' State Insurance Corporation for adding or removing members from an insured person's family. It contains fields to provide details of the family member being added/removed such as name, date of birth, relationship to insured person, reason for change, and whether they reside with the insured. The insured person must declare that the information provided is true and submit photographs of any added family members. The employer must countersign the form after verifying the details.

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    This document is a family declaration form from the Employees' State Insurance Corporation for adding or removing members from an insured person's family. It contains fields to provide details of the family member being added/removed such as name, date of birth, relationship to insured person, reason for change, and whether they reside with the insured. The insured person must declare that the information provided is true and submit photographs of any added family members. The employer must countersign the form after verifying the details.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    413 views1 page

    Employees' State Insurance Corporation: Addition/ Deletion in Family Declaration Form

    Uploaded by

    nasir ahmed
    This document is a family declaration form from the Employees' State Insurance Corporation for adding or removing members from an insured person's family. It contains fields to provide details of the family member being added/removed such as name, date of birth, relationship to insured person, reason for change, and whether they reside with the insured. The insured person must declare that the information provided is true and submit photographs of any added family members. The employer must countersign the form after verifying the details.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    www.esicoimbatore.

    org

    EMPLOYEES’ STATE INSURANCE CORPORATION


    REG. FORM - 2

    ADDITION/ DELETION IN FAMILY DECLARATION FORM


    (Regulation 15 B)

    Name of the Insured Person ………………………………………Insurance No.

    I declare that the person/ persons whose particulars are given below has/ have now become/
    ceased to be member(s) of my family.*

    Sl. Name Date of Reason(s) Relation- Whether If no, where Name of


    No. Birth for change ship with residing residing IMP/Disp.
    & date the Insured with attached.
    Person him/her or
    not, state
    Yes No Distt. State

    I hereby declare that the particulars given above are true to the best of my knowledge and belief.

    Necessary changes may kindly be made in my Declaration Form submitted earlier.

    Passport size photographs of the members who are added to family is/ are enclosed.

    Place.................................... .….............................................................……..
    Signature/thumb impression of the employee
    Date.....................................

    Particulars of the Employer: - Name in Block Letters

    Name :.....................……………..

    Address:.....................…………….. Countersignature of the employer


    .....................………………………..

    Code No.....................……………..
    ...............................………………..
    Designation with Rubber Stamp

    Note: “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 unmarried daughter ; (iv) a child who is infirm by reason of any
    physical or mental abnormality 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).

    *Please submit duly attested copy of the Birth/ Death Certificate.

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