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 PERSON’S PARTICULARS (b) EMPLOYER’S PARTICULARS

1. Insurance No. Employer’s Code
2 Name (in block No.
letters) 10. Date of Day Month Year
Father’s/Husband’s Appointment
Name 11. Name & Address of the Employer
Date of Birth D M Y Marital M/U/W _____________________________
Status _____________________________
_____________________________
6.Sex M/F
7. Present Address 8. Permanent Address 12. In case of any previous employment
______________________ ______________________ please fill up the details as under:-
______________________ ______________________ a) Previous Ins.No.
______________________ ______________________
b) Emplr’s Code No.
______________________ ______________________
C) Name & address of the Employer
Pin Code …………………………… Pin Code ……………………………

e-mail address e-mail address

Branch Office Dispensary 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. Name Date of Birth/ Age Relationship with Whether If’No’, state place of
No. as on date of the Employee residing with Residence
filling form him/her?
Town State Yes No
1.
2.
3.
4.
5.
6.
………………..………………………………………………………………………………………………………………………………………………………………

ESI Corporation (Valid for 3 months from the date of appointment)

Temporary Identity Card

Name

Ins.No. Date of appointment

Space for photograph
Branch Office Dispensary

Employer’s Code No. &

Address

Validity:

Dated: Signature/T.I. of I.P Signature of B.M. with Seal

1. 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. Name Date of Birth/Age Relationship Whether If ‘No’, state place

No. as on date of with the residing with of Residence
filling form Employees him/her?
Yes No Town State
1
2
3
4
5
6
 (FORM 2 REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Funds and Employees Pension Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the Employees
Pension Scheme 1995)

1. Name (IN BLOCK LETTERS) : _______________________________________________________________________________

Name Father’s / Husband’s Name Surname

2. Date of Birth : ___________________ 3. Account No. ___________________

4. *Sex : MALE/FEMALE: ______________________ 5. Marital Status ________________________________________

6. Address Permanent / Temporary : _____________________________________________________________________________

________________________________________________________________________________

PART – A (EPF)
I hereby nominate the person(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 of my death.
If the nominee is minor
Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee

1 2 3 4 5 6

1 *Certified that I have no family as defined in para 2 (g) of the Employees Provident Fund Scheme 1952 and should I
acquire a family hereafter 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 Signature/or thumb impression

of the subscriber

PART – (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 premature death in service.

Sr. No Name & Address of the Family Member Age Relationship with the member

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

Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish Particulars there on in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the
event of my death without leaving any eligible family member for receiving pension.

Name and Address of Date of Birth Relationship with member

the nominee

Date ___________________

Signature or thumb impression

of the subscriber

____________________________________________________________________________________________________________

CERTIFICATE BY EMPLOYER

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

Date : _____________________ Signature of the employer or other authorised officer of the

establishment

Place :
Name & address of the Factory /Establishment
Date :
 Form No. 11 (New)
Declaration Form
(To be retained by the Employer for future reference)

Employees’ Provident Fund Organization

THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57)
&
THE EMPLOYEES’ PENSION SCHEME, 1995 (PARAGRAPH-24)

DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES’ PROVIDENT FUND SCHEME,
1952 AND/OR EMPLOYEES’ PENSION SCHEME, 1995 IS APPLICABLE.
(PLEASE GO THROUGH THE INSTRUCTIONS)

1) NAME (TITLE)
MR . MS. MRS.
(PLEASE TICK)

2) DATE OF BIRTH D D M M Y Y Y Y

3) FATHER’S/ MR .
HUSBAND’S NAME

4) RELATIONSHIP IN RESPECT OF (3) ABOVE FATHER HUSBAND

(PLEASE TICK)

5) GENDER MALE FEMALE TRANSGENDER

(PLEASE TICK)

6) MOBILE NUMBER
(IF ANY)

7) EMAIL ID (IF ANY)

8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952 ?

(PLEASE TICK) YES NO
9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995?
(PLEASE TICK) YES NO
IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILS
AT (10,11&12):
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 A. PREVIOUS EMPLOYMENT DETAILS
10)THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:

UAN
OR
PREVIOUS PF MEMBER ID REGION CODE OFFICE CODE ESTABLISHMENT ID EXTENSION ACCOUNT NUMBER

11) DATE OF EXIT FOR PREVIOUS D D M M Y Y Y Y

MEMBER ID (DD/MM/YYYY)

12) (A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:___________
(B) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER:______________

B. OTHER DETAILS

13) INTERNATIONAL WORKER YES NO

(PLEASE TICK)

IF THE REPLY TO (13) ABOVE IS YES, THEN ENTER THE DETAILS IN 13(A), 13(B) & 13(C):
13(A) COUNTRY OF ORIGIN (Please Tick)
INDIA OTHER THAN INDIA (IF YES, PLEASE
MENTION NAME OF THE COUNTRY)

13(B) PASSPORT NUMBER ______________________________

13(C) PASSPORT VALID FROM

D D M M Y Y Y Y

To D D M M Y Y Y Y

14) EDUCATIONAL ILLITERATE

NON-
MATRIC
SENIOR
GRADUATE
POST
DOCTOR
TECHNICAL/
QUALIFICATION MATRIC SECONDARY GRADUATE PROFESSIONAL
(PLEASE TICK)

15) MARITAL STATUS MARRIED UNMARRIED WIDOW/ WIDOWER DIVORCEE

(PLEASE TICK)

16) SPECIALLY ABLED YES NO IF YES, TICK THE CATEGORY

(PLEASE TICK) LOCOMOTIVE VISUAL HEARING

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17) KYC DETAILS KYC DOCUMENT TYPE NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF ANY
BANK ACCOUNT-1* IFSC CODE*
NPR/AADHAAR
PERMANENT ACCOUNT
NUMBER (PAN)
PASSPORT EXPIRY DATE
DRIVING LICENCE EXPIRY DATE
ELECTION CARD
RATION CARD
ESIC CARD
* Mandatory Field (NOTE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS MANDATORY. YOU
ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE WITH YOU IN ADDITION TO MANDATORY KYCS TO
AVAIL BETTER SERVICES. SELF-ATTESTED PHOTOCOPIES OF THE DOCUMENTS MUST BE ATTACHED WITH THIS FORM.

C. UNDERTAKING:
A. I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
B. IN CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,
(I) I HAVE ENSURED THE CORRECTNESS OF MY UAN/ PREVIOUS PF MEMBER ID.
(II) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM
THE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE POSSIBLE
ONLY IF THE IDENTIFIED KYC DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY PRESENT
EMPLOYER USING HIS DIGITAL SIGNATURE CERTIFICATE).
(III) I AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL.

DATE:
PLACE: SIGNATURE OF MEMBER
DECLARATION BY PRESENT EMPLOYER
A. THE MEMBER Mr./Ms./Mrs. ………………………….. HAS JOINED ON ………………….. AND HAS BEEN ALLOTTED PF MEMBER ID
…………………………………………...
B. IN CASE THE PERSON WAS EARLIER NOT A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
 (POST ALLOTMENT OF UAN) THE UAN ALLOTTED FOR THE MEMBER IS …………………………
 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
C. IN CASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
 THE ABOVE MEMBER ID OF THE MEMBER AS MENTIONED IN (A) ABOVE HAS BEEN TAGGED WITH HIS/HER UAN/PREVIOUS
MEMBER ID AS DECLARED BY MEMBER.
 PLEASE TICK THE APPROPRIATE OPTION:-
□ THE KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE HAVE BEEN APPROVED WITH DIGITAL
SIGNATURE CERTIFICATE AND TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL.
□ AS THE DSC OF ESTABLISHMENT ARE NOT REGISTERED WITH EPFO, THE MEMBER HAS BEEN INFORMED TO FILE
PHYSICAL CLAIM (FORM-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT.

DATE: SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT

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