EMPLOYEES' STATE INSURANCE CORPORATION

e-Pehchan Card

Insured Person : Gadula Rajinadiu THIS CARD IS VALID up to 03/02/2017 *(If Aadhaar number is not entered)
Insurance No. : 5212787033 For extending the validity, please get the Aadhaar number of self and family
Date of Registration : 05/01/2017 seeded through Employer/staff of ESIC/IP portal or visit a Pehchan Camp
along with family for giving Bio-metrics/Photograph.

YOUR REGISTRATION DETAILS

Employee Name: Gadula Rajinadiu Type of Disability : None

Name of Father / Husband: Gudula Appala naidu Date of Birth : 03/02/1992

Marital Status : Unmarried Gender : Male

Gorlipeta Gorlipeta
Present Address : Permanent Address :
Ramathreetham(Post),Nellimarla(Mndl) Ramathreetham(Post),Nellimarla(Mndl)
Vizianagaram (Dist) Vizianagaram (Dist)
-535218,Dist:Vishakapatnam,Andhra -535218,Dist:Vishakapatnam,Andhra
Pradesh
Aadhaar : 798922433392 Aadhaar Status : Unverified

Dispensary / IMP : Vizianagaram, AP (ESIS Disp.)

Current Employer Details First Employer Details

Employer's Code No. : 52000513430000999 Employer's Code No. : None

Sub Unit's Code No. : None Sub Unit's Code No. : None
Date of Appointment : 05/01/2017 First Insurance No. : None

Name of Employer : V-PACK CONSULTANCY SERVICES Name of Employer : None

# 10-192/1, SANJAY GANDHI
Address of Employer : Address of Employer : None
NAGAR,,SHAPUR NAGAR, IDA
JEEDIMETLA,,HYDERABAD.,Dist:Rangared
dyTelangana500055

Family Details:
Relationship Whether
Name Date of Birth State District Aadhaar Aadhaar Status
with the Residing with
Employee Insured Person
Gudula Dependant father
01/01/1971
Andhra Vishakapatna
238161552628 Unverified
Yes
Appalanaidu Pradesh m

Gudula Annapurna Dependant mother

01/01/1976
Andhra Vishakapatna
295678843118 Unverified
Yes
Pradesh m

Nominee Details:
Name of Nominee Relationship with IP Percentage Address of Nominee Aadhaar Aadhaar Status
Gudula Annapurna Dependant mother same,Andhra
100 295678843118 Unverified
PradeshDist:Vishakapatnam
Documents Uploaded:
none

Signature / LTI of Registered Employee / IP :

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

Mobile Number : 7680816468

NOTE:
1. Please keep this printout for future reference and bring this along with your Photo ID for all your Claim Benefits and Medical Benefits.
2. This copy should be retained with you until the Pehchan Card is received.
3. Employer to please affix employee and his family photo here and attest with official stamp across .

* If Aadhaar number is present, this e-Pehchan Card is valid till IP is eligible for treatment.

Signature / Stamp of ESIC Officer / Employer