EMPLOYEES STATE INSURANCE CORPORATION

TEMPORARY IDENTITY CERTIFICATE

Insured Person : Syed Mohamed Pathahulla
Insurance No : 6633120495
Date of Registration :13/07/2012

YOUR REGISTRATION DETAILS

Employee Name :

Syed Mohamed Pathahulla

Type of Disability :

None

Name of Father / Husband:

shahul hameed.A.M

Date of Birth :

07/12/1978

Marital Status :

Married

Gender :

Permanent Address

15 I / 1 Bangalow Street,pettai, Tirunelveli 4.,Dist:Tirunelveli,Tamilnadu,627004

Present Address :

15 I / 1 Bangalow Street,pettai, Tirunelveli 4.,Dist:Tirunelveli,Tamilnadu

Tirunelveli, TN (ESIS Disp.)

Dispensary / IMP :
Current Employer Details

Previous Employer Details

Employer's Code No. :

66000406980000910

Employer's Code No. :

None

Sub Unit's Code No. :

None

Sub Unit's Code No. :

None

Date of Appointment :

02/04/2012

Previous Insurance No. :

None
None

Name of Employer :

RAJADEEAN JEWELLERY

Name of Employer :

Address of Employer :

181/A/5, S.N. High

Road,,Tirunelveli,Dist:TirunelveliTamilnadu6
27001

Address of Employer :

Family Details:
Name

Relationship with the Employe

Date of Birth

None

Whether Residing with I

State

District

A.M.SAHUL HAMEED

Dependant father

20/05/1948

Yes

Tamilnadu

Tirunelveli

S.DAWOOD PATHU

Dependant mother

30/03/1955

Yes

Tamilnadu

Tirunelveli

S.HAJARA BANU

Spouse

13/12/1986

Yes

Tamilnadu

Tirunelveli

S.ABDUL HAMEED

Minor dependant son

21/02/2011

Yes

Tamilnadu

Tirunelveli

S.Katheeja

Dependant unmarried daughter

12/12/2013

Yes

Tamilnadu

Tirunelveli

Nominee Details:
Name of Nominee

Hajara Banu.S

Relationship with IP

Spouse

Percentage

100

Address of Nominee

15 I / 1 Bangalow Street,pettai,Tirunelveli.,TamilnaduDist:Tirunelveli627004

Documents Uploaded:
none

Please Verify the Above Particulars.

Please Notify Your Employer or in the Branch Office Address Below Incase of Any Information Found Incorrect.
To get permanent ID card, employee is requested to visit the following branch office to get biometric & photo captured by this date
28/07/2012 , in the Below Branch Office : BO-TIRUNELVELI,182/E4/33, S.N. High Road, Opp. To State Bank of India, Tirunelveli,627001

or any nearest ESIC Bio-metric Camp Locations.

Signature / LTI of Registered Employee / IP :

Mobile Number :

Affix Your Family Photograph Here.(Attested and Stamped by Employer / ESIC Official)

9688643013

NOTE:
1. Please Keep this Printout for Future Reference and Bring this Along with Your Photo ID Card for All Your Claim Benefits and Medical Benefits .
2. This Copy Should be Retained with You until the Biometric Card is Dispatched .
3. Employer to please affix employee and his family photo here and attest with official stamp across .
Signature / Stamp of ESIC Officer / Employer