‘GIT TA DECLARATION FORM wrt/Fonn-t shoo ar aah rer er ET eh er re saree a wet oA oe og we Se hee yew a me Recreate vg dar et ae wr Pegs ‘Tobe tiled by employee after reading instruction overlea. Two Postcard Size phtographs to be attached withthe form. This frm is tree of cost. () Borge eer & Pere () Pritwe @ Praer (A) INSURED PERSON'S PARTICULARS (8) _ EMPLOYER'S PARTICULARS: 1. ata eATAnaurance No. [s. Reser er Goo Pees (RAD ShARMA | [eae ears = ae |e ava aT (ate ar hpeatanert Day | Month | voor P Faterstunbrs Hand HARI ES HARM = S115 fi. aie ara a Wa Name & Adsess ofthe Employer La Ba] aear| a] Bae | Pae” Py Dato of ith Day Montfvea| “ater \saater| | == Convey Rolie a TY Maral feet : Status | MUN | Fae Fea or TE LOR [Sal etsexlem per] | _lcseotany pees enpymentlas te ta os er rar wavProsont Address [sear eavPermanent Adress | |) Feat sre (2) Provous Ins. No. —— eer e er i (o) Employers Code No, Ss Boy Cy Code —~ Pree pee aaaavos. [SMa taareeat ne Empyer 4 Brach Ofce Denereay 08) ROMER. [sie ere wavemallacose (hay RR oe ere are gm, Fa, tose i are Tierra (Se) Fre, 1050S rw 36) sir ar (@) etal of Nominee ule 71 of ESI Act 1946/Rulo-56(2) of ES! (Contra) Rules, 1950 for payment of cash benef inthe event of death. Wehane ‘wea Reitonsip wana PDURRISEM CHARNAT TERTHER. TIMER ugar ee aera Pe AE er fe re Free ret le arr aeqare wah 81 ore aac ace Hey ted eT ser seer eet eer her CO "roby decalare that tho patculare given by me are corct othe bes of my knowiodge and boll. undertake to intimate the corporation any changes in the momberchlp of my family within 18 day of such change, Ret & after stooge air & were ier Pert (Counter signature bythe employer ‘Signature Tf P ‘te of rarer ‘Signatur wth sal (0 orgs eas Pe ot Ree (0) Famay Paras of sured person ma a Wada | atm | woes st No. Name at organs | Relationship withthe eh ant pate ot Srtvage as on Empyer Wrater residing dat fing form with hier ies Mm ‘waa Bre re wou ot (Reger ot ats 3 nA os te) SI Corporation Temporary Monty Card (Wal for3 month om the date of appointment) Name Far Tavine, No, Tighe atta Dato of ppolnimont ‘war are shearer a3 fe Branch Offce Dispensary {Space for photograph) fave de don var Employers Code No. & Address tn Volt ta terge afr & eet feat ‘ry afer arn were ee Dated ‘Slonature/ of LP, ‘Slanaiure of BM, wih seal