EMPLOYEES' STATE INSURANCE — DECLARATION FORM (FORM 1)
Declaration under Regulation 11 & 12 of the ESI (General) Regulations, 1950 for registration of an employee as an Insured Person under the ESI Act, 1948.
Employer / Establishment: [Company Name] ESIC Employer Code: [__________]
| Name of Employee | [Employee Name] | Insurance No. (if any) | [__________] |
| Father's / Husband's Name | [Name] | Date of Birth | [DD/MM/YYYY] |
| Sex / Marital Status | [__________] | Date of Appointment | [DD/MM/YYYY] |
| Present Address | [Address] | ||
| Permanent Address | [Address] | ||
| Aadhaar No. | [__________] | Bank A/c & IFSC | [__________] |
| Nominee (Cash Benefit) | [Name] | Relationship | [Relationship] |
Particulars of Family Members eligible for Medical Benefit:
| Name | Relationship | Date of Birth | Whether residing with IP | Dispensary |
|---|---|---|---|---|
| [Name] | [Relationship] | [DD/MM/YYYY] | [Yes/No] | [Dispensary] |
| [Name] | [Relationship] | [DD/MM/YYYY] | [Yes/No] | [Dispensary] |
I declare that the particulars above are true. Date: [DD/MM/YYYY] _______________________
Signature / Thumb impression of Employee
Employer's certificate: The above person has been employed by us w.e.f. [DD/MM/YYYY]. _______________________ (Employer)
Compliance note: ESI applies where wages are up to ₹21,000/month (₹25,000 for persons with disability). Register the employee online within 10 days of joining to obtain the IP number and e-Pehchan card.