ater fafran 11 a 12 waa t DECLARATION FORM REGULATION 11 & 12 FORM 1 ae th Fe we re & a aria eh 1 E.S.LC. (To be filed in only ifthe employee has not insured earlier) oo iver fae eR 9 Serial No. in retun of Declaration Form No.8 ert ale S Reet (eee & een (A) INSURED PERSON'S PARTICULAR (8) EMPLOYER'S PARTICULARS fv weaneurance Ne ow ae wo Empyers Cade No, ala wigan ate ea Jame tn block eters) DateotAmponimen | er] norm | umm h 7a en —==a Preah Te Tracom Jes Joon Fe oes ety Speers oe eat ruin Date of ian fe [ats Pe Tee — art sts = —_ Perret ry fe Seal 7a in Gar ofan prevou enorme esse upe es sre TR w/Free hone [ow ox/PemanertAatio) fs ae sire ama —= | Beree oeeeeeceeeas — Blea ae ao aaere ra frie ima Shame tna Poe OOOO jer oi eon sat aoa eciess [Ems rane ae fr wrlae bisa Eres = ns | Dg A Ret Awe Beer gram @ Re wad alien we @ we 11/eue (Oa) Rew ime Duy eae ART ©) Dette ef Nerinee us 7 of ESI Act 124/Rule-86 2) of ES (Canta Pls 86D fr pment e cash ore et eo, ame a Retionahp ea nde iret 28 Se arch re € Hee weg A Re STA ate Pera & aE BY aA ae A ce By Reda Que we Pa 2 sae weg et BF aero be L/S ! hereby decate thet the pateula's given by me are covect othe best of my knowledge and belive. | undertake to innate the Corporation ‘any Charges in the membership of my family within 18 days of such charge, Pras @ ae ‘Counter signature by the employer fe aa re tor a Wom sa Fret ‘Signature win seal ‘Signature. of P 0 ang ais & we fae (0) Fanny Paricutars of Insured Person wed | an/Name wile a aera aa ae ae aT en SRE, | Relationship wah ne | Whether residing wah | No State place of Reeiderco Dato of rage as beet Brtyhge as | emptyee tires, soy ” ves |S 1No | ve tomn | eal SSS Sag hasan or ESI Corporation Temporary identity Card raf A ete #3 fr os te) (ioisior mons tome ate spine) Fame 1 tonne, ae wen/ One trea pt | aeanas Vissengan 2 fe oe Branch Oe (Space fr Photograph) eee