HDB Financial Services Limited

2nd Floor, Wilson House,

Old Nagardas Road,
Near Amboli Subway,
Andheri East, Mumbai - 400069
Tel. : 022 - 7945 5000
Email : [email protected]
Web : www.hdbfs.com
CIN - U65993GJ2007PLC051028

May 8, 2023
Ref:HDBFS/23-24/HRIC402628/Appt/P41834
Mr.Prakhyath A Shetty,
House No 402,
Sanath Sadan ,
Rk Garden,New Bel Rd ,
Near Ms Rammaiah College ,
Bangalore-560094

Dear Mr.Prakhyath A Shetty,

LETTER OF APPOINTMENT

Further to your application and subsequent discussions for employment, HDB Financial Services Limited (“Company”)
is pleased to appoint you as SALES EXECUTIVE on the terms and conditions as set out below.

Your Total Salary per annum is set out as attached in Annexure A. All remuneration, benefits and perquisites will be
taxed in accordance with the provisions of Income Tax Act, 1961 and any other enactments in force from time to time.

Terms and Conditions:

a) Your duties and responsibilities will be explained to you on your joining the Company.

b) Your initial place of posting will be at BANGALORE. The Company reserves the right to change the duties assigned
to you, transfer you, temporarily or permanently, to any other office / branch, subsidiary or associate of the
Company or to any other place of business of the Company that is in existence or may come into existence at a future
date. The Company further reserves the right to transfer you from one shift to another, depending upon the
exigencies of work.

c) You shall devote your whole time and attention to your duties with the Company and will not directly or indirectly,
for any part of your time carry on any business or occupation or enter in any capacity, the employment of or
association in business for profit or otherwise, with any firm, company or person without the prior written consent of
the Company.

d) You shall abide by all the applicable policies, rules, regulations, procedures and practices of the Company, as may be
amended, from time to time and comply with all applicable Laws. Any violation of or failure to comply with or abide
by the same shall be deemed to constitute an act of misconduct.

Registered Office : Radhika, 2nd Floor, Law Garden Road, Navrangpura, Ahmedabad-380 009.

Page 1 of 5
e) You will be responsible for the safe keeping and return in good condition and order, of any properties and / or assets
which may be entrusted to you by the Company. The Company shall have the right to deduct the money value of all
such properties and / or other assets from your dues and take such other action as it may deem proper in the event of
your failure to account for such properties to the Company’s satisfaction.

f) You shall not, during your employment with the Company or at any time thereafter, discuss, divulge, or make
public, directly or indirectly, to any individual, firm, company or person of any nature whatsoever, any information,
processes, policies, documents, research, development, finances, properties, contracts, methods, trade secrets,
transactions, or generally in relation to the business and affairs of the Company (including its subsidiaries and
associate companies) or its clients, customers, employees, management, or business associates, which you may
acquire during the course of, or which may otherwise come to your knowledge or possession during the course of
your employment with the Company.

g) This letter of appointment can be terminated by either party by giving One month's notice in writing. It is clarified
that, in the event of a termination of this Agreement by you, the decision whether or not to accept salary in lieu of the
notice period will rest solely with the Company and you may be required to serve the applicable notice period
instead of paying to the Company an amount equivalent to your salary in lieu thereof. The Company may, at its sole
discretion, require you to proceed on leave during your notice period. Upon the termination of this letter of
appointment, you will be required to comply with the Company’s exit formalities.

h) If at any time, you are found to be overstaying your sanctioned leave or are absent from work without permission for
a period exceeding 5 (five) consecutive days or are found to be habitually absent or are otherwise found guilty of
dishonesty, disobedience, fraud, insubordination, riotous and disorderly behaviour, negligence, indiscipline or any
other act of misconduct (as determined by the Company in its sole discretion), then the Company will be entitled to
terminate your services with immediate effect without giving you a notice or salary in lieu thereof.

i) Nothing contained herein constitutes a guarantee of employment. Your performance shall continuously be evaluated
by the Company. If you are found to be incompetent in the discharge of your duty or do not meet the productivity
norms, your services shall be terminated. The Company reserves the sole right to terminate your employment on
grounds of performance not being up to expected standards. The final decision of the management in this regard
shall be final.

j) Notwithstanding anything contained in the above paragraphs, your services may be terminated by the organization
if you are found to be indulging in acts of commission / omission which may be prejudicial to the interest of the
organization, or any act of dishonesty, disobedience, insubordination or any other misconduct or neglect of duty or
incompetence in discharge of duty on your part.

k) In the event of any allegation of misconduct against you, the Company will initiate disciplinary proceedings against
you as per its rules in this regard.

l) You will keep the Company informed of any change in your residential address or in any of the other information
pertaining to you as provided to the Company. All communication sent by the Company on the address registered in
our records, will be construed as communication served on you.

Ref:HDBFS/23-24/HRIC402628/Appt/P41834 Page 2 of 5
m) You will retire from the employment of the Company on your completing 60 (Sixty) years of age. It will be necessary
for you to produce proper proof of your age within 7 (seven) days on receipt of this letter as may be required by the
Company.

n) This letter of appointment shall be governed by and construed in accordance with the laws of India. The terms and
conditions set out in this letter of appointment constitute service conditions applicable to your employment in the
organization and any dispute arising out of this letter of appointment or pertaining to your employment shall be
subject to the exclusive jurisdiction of the courts of Mumbai.

o) You shall comply with the data protection policy of the Company when handling personal data in the course of your
employment with the Company including personal data relating to any employee, customer, client or agent of the
Company or any of its affiliates and you shall promptly report any breaches or anticipated breaches of the same.

p) You consent to the Company, its affiliates processing data relating to you for legal, personnel, administrative and
management purposes and in particular to the processing of any “sensitive personal data or information” (as defined
in the policies of the Company). The Company may make such information available to any of its affiliates, those
who provide products or services to the Company or any of its affiliates (such as advisers and payroll
administrators), regulatory authorities, potential purchasers of the Company or the business in which you work, and
as may be required by law. You also consent to the Company carrying out the above activities and other similar
classes of activities prior to, during and after the termination of your employment with the Company, provided that
such activities are carried out in a lawful manner and for legitimate purposes.

q) If at any time during your employment you make, develop, discover or participate in the making or discovery of any
“Intellectual Property Rights”(as defined in the policies of the Company) relating to or capable of being used in the
business being carried on by the Company or any of its affiliates, such Intellectual Property Rights shall be the
absolute property of the Company. At the request of the Company you shall execute all such documents and do all
acts, matters and things which may be necessary or desirable for obtaining registration or other protection for the
Intellectual Property Rights as may be specified by the Company.

r) You hereby acknowledge and undertake that you do not have and shall not have at any point of time, any
ownership, interest, right or title in the Intellectual Property Rights nor will you claim any ownership, interest, right
or title in the Intellectual Property Rights or brand forming part of the business of the Company or any of its
affiliates.

s) You shall not, at any time during the course of your employment and any time after the termination of your
employment with the Company, make any statement, representation, post commentary, content or image or
communicate in writing, orally or otherwise or take any action directly or indirectly in public or private, in any
manner or through any medium whatsoever including but not limited to newspaper, social media, e-mail, SMS,
internet, blog, social networking websites etc., which may directly or indirectly, defame or disparage the image,
credibility, good name, goodwill and reputation of the Company or any of its officers, directors, employees, agents,
consultants, representatives etc. or create an hostile work environment.

t) Your appointment will be subject to the organization receiving satisfactory references and Contact Point verification
report.

Ref:HDBFS/23-24/HRIC402628/Appt/P41834 Page 3 of 5
u) Any variation of the above terms and conditions will not be valid until expressly made in writing by the Company.

v) This letter of appointment (together with all its annexures) shall supersede all prior, oral or written agreements or
communications, formal or informal, in relation to your employment with the Company.

As your acceptance to these terms of employment, please sign the duplicate copy of this letter of appointment in the
space provided below and return the same to us.

You are requested to join no later than May 23, 2023.

Kindly arrange to bring self-attested copies of the following documents along with their originals for verification on the
date of your joining:

a) Copy of Educational Certificates and Marksheets (Xth, XIIth, Graduation, Post Graduation)
b) Proof of date of birth (Copy of driving license, Voter ID, Passport)
c) Duly signed duplicate copy of Appointment Letter
d) Copy of Pan Card and Aadhaar Card (Both documents are required for Salary processing)

You will be required to complete the Company's prescribed joining formalities within 3 (three) working days from the
date of your joining and submit the same to the Human Resources Department for necessary processing of your Salary.

Yours Sincerely,
For HDB Financial Services Ltd.

Smily Mehra
HBL Global - a division of HDB Financial Services Limited.

AGREED AND ACCEPTED

_____________________________________
Mr.Prakhyath A Shetty

Ref:HDBFS/23-24/HRIC402628/Appt/P41834 Page 4 of 5
 Annexure A

Compensation Breakup

Name MR.PRAKHYATH A SHETTY

Role Sales Executive

Grade G7

Location Bangalore

Annual Compensation Break up HDBFS Monthly

Basic 1,12,500 9,375

HRA 45,000 3,750

Conveyance Allowance 22,500 1,875

Provident Fund (Employer's contribution) 16,200 1,350

Gross Salary (A) 1,96,200 16,350

ESIC (Employer's contribution)----(B) 5,119 427

Gratuity----------- (C) 5,411 451

Total Fixed Compensation (D=A+B+C) 2,06,730 17,228

Note:

This Offer is subject to positive Contact Point Verification, Reference checks &
CIBIL/SAS check. Your consent for candidature of the company will be considered as
consent for accessing your CIBIL report.

Employee and Employer’s contribution towards ESI will be 0.75% & 3.25%
respectively

You will be entitled to Performance Incentive Plan as per Company Policy

Gratuity is as per “The Payment of Gratuity Act”.

You will be covered under Group Personal Accident Insurance as per policy of the
Organization

Ref:HDBFS/23-24/HRIC402628/Appt/P41834

I accept the terms and conditions as mentioned in the Appointment letter.

_____________________________________
Mr.Prakhyath A Shetty
 Offer ref # P41834

SPECIMEN FORM 2 (REVISED)

GROUP No. :
NOMINATION & DECLARATION FORM
Office :
FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Funds

and Employees Pension Scheme

(Paragraph 33 & 61 (1) of the Employees Provident Funds Scheme, 1952 and
Para 18 of the Employees Pension Scheme, 1995)

1. NAME (in block letters ) : Prakhyath A Shetty

2. FATHER'S / HUSBAND'S NAME : Anil Kumar N Shetty
3. DATE OF BIRTH : 31-Jul-2001
4. SEX : Male
5. MARITAL STATUS : Single
6. ACCOUNT NO : MH / BAN / 49611
7. ADDRESS : H No 2-232/1,
Anugraha Gandottu H,
KANNADA - 574142

PART - A (EPF)

I hereby nominate the persons(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 my death.

Total amount or
share of If the nominee is minor, name & relationship &
Name & Address of the Nominee(s) Nominee's relationship with accumulation in PF add. of the guardian who may receive the
the member Date of Birth to be paid in each amount during minority of nominee
nominee

(1) (2) (3) (4) (5)

Anil Kumar N Shetty, House No 402, Sanath Sadan , Father 09 - Sep - 1965 100 No
Bangalore- 560094

1. * Certificate that I have no family as defined in para 2 (g) of the Employees Provident Funds Scheme, 1952 and should I acquire a family thereafter
the above nomination should be deemed as cancelled.
2. * Certified that my father / mother is / are dependent upon me.
(*) Strike out whichever is not applicable.

X ________________________________________________________
SIGNATURE OR THUMB IMPRESSION THE SUBSCRIBER
 Offer ref # P41834

PART - B (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 death.

Sr. No. Name & Address of the family member/s Date of Birth Relationship with Member

(1) (2) (3) (4)

1 Anil Kumar N Shetty, House No 402, Sanath Sadan , Bangalore- 560094 09 - Sep - 1965 Father

**Certified that I have no family, as defined in para 2 (vii) of the Employees Pension Scheme, 1995 and should I acquire a family here after I shall
furnish particulars thereon in the above form.
I hereby nominate the following person for receiving the monthly family pension (admissible under para 16 (2) (i) and (ii) in the event of my death
without leaving and eligible family member/s for receiving pension.

Name of the Nominee Address Date of Birth Relationship with

Member

(1) (2) (3) (4)

Anil Kumar N Shetty House No 402, Sanath Sadan , Bangalore- 560094 09 - Sep - 1965 Father

Date : 01-Jun-2023 X
_________________________ _________________________________________________________________
(*) Strike out whichever is not applicable SIGNATURE OR THUMB IMPRESSION THE SUBSCRIBER
_______________________________________________________________________________________________________________________________________________________

CERTIFICATE BY EMPLOYER
CERTIFICATE that the above declaration and nomination has been signed / thumb impressed before me.

by Shri / Smt. / Miss. ________________________________________________________________________________________________ employed in my / our establishment

after he / she has read the entire / the entries have been read over to him / her by me and confirmed by him her

For HDB Financial Services Limited

Place : __________________ Authorized Signatory

Date : ________________________________________________________________________________
Signature of the Employer's OR other Authorised Officer's the Establishments
Signature with Designation
HDB Financial Services Ltd
Ground Floor, Zenith House, Keshavrao Khadye Marg,
Opp.Race Course, Mahalaxmi, Mumbai - 400034.
 Offer ref # P41834

UNDER THE PAYMENT OF GRATUITY ACT, 1992.

&
THE PAYMENT OF GRATUITY (MAHARASHTRA) RULE, 1972

FORM 'F'
(See Sub-Rule (i) of rule (6)

Nomination

To
M/s HDB Financial Services Limited
Ground Floor, Zenith House,
Keshavrao Khadye Marg,
Opp.Race Course, Mahalaxmi
Mumbai - 400034.

1. Shri / Shrimati / Kumari PRAKHYATH A SHETTY whose 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 event of my death before that
amount has become payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in
proportion indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is / are member(s) of my family within the meaning of clause (h) of section 2 of the Payment of
Gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of section (2) of the said Act.

4. (a) My father / mother / parents is / are not dependent on me.

(b) My husband's father / mother / parents is / are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the to the controlling authority in terms of the provison to clause(s) of section
2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

NOMINEE (S)
Sr. No. Name If Full address of the nominee(s) - (1) Relationship with the Age of the Nominee Proportion by which the
Employee (2) (3) gratuity will be shared (4)

1 Anil kumar N Shetty,House No 402, Sanath Sadan , Bangalore-

560094 Father 09 - Sep - 1965 100

6
 Offer ref # P41834

Statement
1 Religion Hinduism

2 Sex. Male

3 Name of employee in full. Prakhyath A Shetty

4 Whether married/unmarried/widow Single

5 Department/Branch/Section where Miller's Road

employed

6 Post held with Ticket or Serial Number if any. Sales Executive

7 Date of appointment. 01-Jun-2023

8 Permanent address. H No 2-232/1, Anugraha Gandottu H, KANNADA - 574142

Village Thana Sub-division

Post Office District State

Place : Miller's Road X ____________________________________________

Date : 01-Jun-2023 Signature/Thumb impression of the employee

Declaration by witnesses
I declare that the Nomination has been signed/thumb impressed before me.

Name in full Signature of Witnesses. Address of witnesses

1. ___________________________________________ 1. ______________________________________

2. ___________________________________________ 2. ______________________________________

Place : Miller's Road Place : Miller's Road

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.

Employer's References No., If any.

Designation For HDB Financial Services Limited

Authorized Signatory

HDB Financial Services Ltd __________________________________________________

Ground Floor, Zenith House, Signature/Thumb impression of the Authorized Signatory
Keshavrao Khadye Marg
Opp.Race Course, Mahalaxmi
Mumbai - 400034.

Acknowledgement by the employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

Date _______________________ ___________________________

Signature of the employee

Note : Strike out the words and paragraphs not applicable.

 www.epfindia.com
Composite Declaration Form Form -11
(To be retained by the Employer for future reference) P41834
EMPLOYEES' PROVIDENT FUND ORGANIZATION
Employees' Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in an establishment on which EPFS 1952 and/or EPS 1995 is applicable)

1 Name of the Member

Prakhyath A Shetty
Fathers' Name ✔
2
Spouse's Name Anil Kumar N Shetty
3 Date of Birth (DD/MM/YYYY)
31/07/2001
4 Gender: (Male/Female/Transgender) Male
5 Marital Status(Married/Unmarried/Widow/Widower/Divorcee) Unmarried
6
(a) Email Id: [email protected]
(b) Mobile No.: 9035309400
Present employment details:
7 01/06/2023
Date of joining in the current establishment (DD/MM/YYYY)

KYC Details (attach self attested copies of following KYCs)

a) Bank Account No.: 40030355314
8 b IFS Code of the branch: SBIN0016279
c) AADHAAR Number: 463676275698
d) Permanent Account No. (PAN), if available NNGPS5939J
Whether earlier a member of Employees' Provident
9 Yes No ✔
Fund Scheme, 1952 ?

Whether earlier a member of Employees' Pension

10 Yes No ✔
Scheme, 1995 ?

Previous employment details [if Yes to 9 &/or 10 above] - Un-exempted

Scheme
PPO Non Contri-
Establishment Universal Account PF Account Date of joining Date of exit Certificate
Number (if butory Period
Name & Address Number Number (DD/MM/YYYY) (DD/MM/YYYY) No. (if
issued) (NCP) Days
issued)

11

Previous employment details [if Yes to 9 &/or 10 above] - For Exempted Trusts
Scheme Non Contri-
Establishment Name & Universal Account Member EPS Date of joining Date of exit Certificate butory
Address Number A/C Number (DD/MM/YYYY) (DD/MM/YYYY) No. (if Period (NCP)
issued) Days
12

a) International Worker: Yes No ✔

b) If yes, state country of origin

13 (India/Name of other country)

c) Passport No.

d)Validity of passport [(DD/MM/YYYY) to (DD/MMYYYY@ From To

 UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge.
2) I authorize EPFO to use my Aadhaar for verification/authentication/eKYC purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the present PF Account as
I am an Aadhaar verified employee in my previous PF Account *

4) In case of changes in above details, the same will be intimated to employer at the earliest.

Date: 01-Jun-2023
Place: Bangalore Signature of the Member
DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs. has joined on

and has been allotted PF Number and UAN

B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:

● 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.e-sign

C. In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995:

● Please Tick the Appropriate Option:

The KYC details of the above member in the UAN database have been approved with E-sign/Digital Signature Certificate and
transfer request has been generated on portal.

The previous Account of the member is not Aadhaar verified and hence physical transfer form shall be initiated.

Date: Signature of Employer with Seal of Establishment

* Auto transfer of previous PF account would be possible in respect of Addhaar verified employees only. Other employees to fill physical claim (Form-13) for
transfer of account from pervious establishment.
 ?kks"k.kk i=k DECLARATION FORM Offer Ref # P41834 QkeZ&1@Form-1
?kks"k.kk i=k deZpkjh }kjk Hkjk tk,xkA QkeZ ds LkkFk iksLVdkMZ vkdkj ds nks QksVksxzkQ Hkh yxk, tkus pkfg,A QkeZ Hkjus ls igys
ihB i`"B ij nh xbZ fgnk;rksa dks Hkyh&Hkkafr i<+ ysuk pkfg,A ;g QkeZ fu%'kqYd gSA
To be filled by employee after reading instruction overleaf. Two Postcard Size phtographs to be attached with the
form. This form is free of cost.
¼d½ chekÑr O;fDr ds fooj.k ¼[k½ fu;kstd ds fooj.k
(A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS

1- chek la[;k@Insurance No. 9- fu;kstd dh dwV la[;k

Employer's Code No.
2- uke ¼Li"V v{kjks esa½
Name in block letters Prakhyath A Shetty 10- fu;qfDr dh rkjh[k
Date of Appointment
fnu
Day
eghuk
Month
o"kZ
Year
3- firk@ifr dk uke 01 06 2023
Father's/Husband's Name Anil Kumar N Shetty 11- fu;kstd dk uke vkSj irk@Name & Address of the Employer
4- tUe dh frfFk fnu eghuk o"kZ 5- oSokfgd fookfgr@ __________________________________________________
Date of Birth Day Month Year izkfLFkfr vfookfgr __________________________________________________
Marital ✔
fo/kok __________________________________________________
Status M/U/W 12- ;fn igys fu;kstu esa jgs gSa rks Ñi;k fuEufyf[kr C;kSjs nhft,
✔
In case of any previous employment please fill up the details as under.
31 07 01 6-fyax@Sex iq-e-/M.F.
7- orZeku irk@Present Address 8- LFkk;h irk@Permanent Address ¼d½ fiNyh chek la[;k
______________________
House No 402 ______________________
H No 2-232/1 (a) Previous Ins. No.
______________________
Sanath Sadan ______________________
Anugraha Gandottu H ¼[k½ fu;kstd dwV la[;k
______________________
Bangalore,Karnataka ______________________
KANNADA,Karnataka (b) Employer's Code No.
fiu dksM 6 0 0 9 4
fiu dksM 7 4 1 4 2
5 5
Pin Code Pin Code ¼x½ fu;kstd dk uke o irk
VsyhQksu uEcj@bZ&esy irk@ [email protected] VsyhQksu uEcj@bZ&esy irk@ 9035309400 (c) Name & Address of the Employer

'kk[kk dk;kZy; vkS"k/kky;

Branch Office Dispensary
VsyhQksu uEcj@bZ&esy irk@e-mail address
¼d½ e`R;q dh fLFkfr esa udn fgrykHk ds Hkqxrku ds fy, d-jk-ch- vf/kfu;e] 1948 dh /kkjk 71@d-jk-ch- ¼dsUnzh;½ fu;e] 1950 ds fu;e 56¼2½ ds varxZr ukfer ds C;kSjsA
(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.

uke@Name ukrsnkjh@Relationship irk@Address

Anil kumar N Shetty Father House No 402,Sanath Sadan ,Bangalore,560094

eSa ,rn~}kjk ?kks"k.kk djrk@djrh gwa fd esjs }kjk izLrqr fd, x, fooj.k esjh tkudkjh vkSj fo'okl ds vuqlkj lgh gSA eSa vius ifjokj ds lnL;ksa esa gq, ifjorZu dh lwpuk
15 fnu ds Hkhrj izLrqr djus dk opu Hkh nsrk gwa@nsrh gwaA
I hereby decalare 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.

fu;kstd ds izfrgLrk{kj chekÑr O;fDr ds gLrk{kj@vaxwBk fu'kku

Counter signature by the employer Signature /T.I.of IP.

lhy lfgr gLrk{kj

X
Signature with seal
¼?k½ chekÑr O;fDr ds ifjtuksa dk fooj.k
(D) Family Particulars of Insured person
Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with the jgs gSa\ crk,a dk LFkku n'kkZ,a
Date of Birth/Age as on Employee Whether residing If' No' state Place of
date of filling form with him/her. Residence
gk¡@Yes ugha@No dLck@Town jkT;@State
1 Anil kumar N Shetty 09-09-1965 Father Yes

d-jk-ch- fuxe vLFkk;h igpku i=k ¼fu;qfDr dh rkjh[k ls 3 eghus rd oS/k½

ESI Corporation Temporary Identity Card (Valid for 3 month from the date of appointment)
uke@Name Prakhyath A Shetty
chek la[;k@Ins. No. fu;qfDr dh rkjh[k@Date
01-06-2023
of appointment
'kk[kk dk;kZy; vkS"k/kky; QksVks ds fy, LFkku
Branch Office Dispensary (Space for photograph)

fu;kstd dh dwV la[;k o irk

Employer's Code No. & Address

oS/krk
Validity
rkjh[k
Dated X chekÑr O;fDr ds gLrk{kj@vaxwBs dk fu'kku
Signature/T.I. of I.P.
lhy lfgr 'kk[kk izca/kd ds gLrk{kj
Signature of B.M. with seal
 vuq n s ' k
Offer Ref # P41834
INSTRUCTIONS

1- QkeZ&1 dk izs"k.k d-jk-ch- ¼lk/kkj.k½ fofu;e] 1950 ds fofu;e 11 o 12 ds varxZr fofu;fer fd;k tkrk gSA
Submission of Form-I is governed by regulation 11 & 12 of ESI (General) Regulations, 1950

2- ßdqVqEcÞ ls fdlh chekÑr O;fDr ds fuEufyf[kr lHkh vFkok dksbZ ukrsnkj vfHkizsr gS%&
vFkkZr~%& ¼1½ fookfgrh ¼2½ chekÑr O;fDr ij vkfJr dksbZ /keZt ;k nÙkd vo;Ld vkfJr ckyd] ¼3½ dksbZ ckyd tks chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS rFkk tks ¼d½ f'k{kk izkIr dj jgk gS] muds 21 o"Z dh vk;q izkIr dj ysus rd ¼[k½ dksbZ vfookfgr iq=kh]
¼4½ dksbZ ckyd tks fdlh 'kkjhfjd vFkok ekufld vilkekU;rk ;k pksV ds dkj.k f'kfFkykax gS rFkk f'kfFkykaxrk jgus rd chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS] ¼5½ vkfJr ekrk&firk] ¼C;ksjs gsrq d-jk-ch- vf/kfu;e] 1948 dh /kkjk 2 ds [kaM 11 dks ns[ksa½A
“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 physcial 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.

3 igpku&i=k vgLrkUrj.kh; gSA

Identity Card is Non-Transferable.

4- igpku&i=k ds xqe gksus dh fLFkfr esa fu;kstd@'kk[kk izca/kd dks rRdky lwfpr fd;k tk,A
Loss of Identity Card be reported to Employer/Branch Manager immediately.

5- fdlh izdkj dh xyr lwpuk nsus dh fLFkfr esa d-jk-ch- vf/kfu;e] 1948 dh /kkjk&84 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
Submission of false information attracts penal action Under Section 84 of ESI Act. 1948.

6- ubZ fu;qfDr dh fLFkfr esa Hkyh&Hkkafr Hkjk gqvk ;g QkeZ fu;qfDr ds nl fnu ds Hkhrj lacaf/kr 'kk[kk dk;kZy; esa vo'; gh izLrqr fd;k
tkuk pkfg,A foyEc dh fLFkfr esa fu;kstd ds fo#) /kkjk&85 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
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- chekÑr O;fDr gksus ds ukrs vki o vkids ifjokj ds vkfJrtu fpfdRlk fgrykHk izkIr dj ldsaxsA vU; udn fgrykHk gSa] ¼1½ chekjh
fgrykHk ¼2½ vLFkk;h viaxrk fgrykHk ¼3½ LFkk;h viaxrk fgrykHk ¼4½ vkfJrtu fgrykHk ¼5½ izlwfr fgrykHk ¼efgyk deZpkjh ds fy,½A
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.

8- vf/kd tkudkjh ds fy;s Ñi;k fuxe ds osclkbV dks nsa[ksa ;k 'kk[kk dk;kZy; ;k {ks=kh; dk;kZy; ls laidZ djsaA
For more details please contact website of ESIC at www. esic.org. in. or contact Regional Office or Branch Office.

dsoy 'kk[kk dk;kZy; esa iz;ksx gsrq

For Branch Office Use only

1- chek la[;k vkoaVu dh rkjh[k %

Date of allotment of Ins. No. :_________________________________________

2- vLFkk;h igpku i=k tkjh djus dh rkjh[k %

Date of Issue of T.I.C. :______________________________________________

3- vkS"k/kky; dk uke@la[;k %
Name /No. of Dispensary : ___________________________________________

4- D;k vU;ksU; fpfdRlk O;oLFkk miyC/k gS\ ;fn gkaa] rks mYys[k djsa %
Whether reciprocal Medical arrangements involved. if yes, please indicate :

'kk[kk izcU/kd ds gLrk{kj

Signature of Branch Manager

Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha] rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with the jgs gSa\ crk,a dk LFkku n'kkZ,a
Date of Birth/Age as on Employee Whether residing If' No, state Place of
date of filling form with him/her. Residence
gk¡@Yes ugha@No dLck@Town jkT;@State
1 Anil kumar N Shetty 09-09-1965 Father Yes