Employee State Insurance Corporation

Employee Registration Form

Please fill in Capital Letters Only
1- EMPLOYEE CODE-
2- NAME-
3- NAME OF FATHER/HUSBAND-
4- DATE OF BIRTH-
5- ID PROOF NO- AADHAR No.
6- MARITAL STATUS- 7- SEX
8- PRESENT ADDRESS- PIN CODE-

PHONE NO-
STATE- MOB. NO-
DISTRICT- EMAIL-
9- PERMANENT ADDRESS- PIN CODE-

PHONE NO-
STATE- MOB. NO-
DISTRICT- EMAIL-
10- In case of any Previous employment please fill up the details below:-
A- EMPLOYER'S CODE NO-
B- PREVIOUS INSURANCE NO-
C- NAME OF THE EMPLOYER-
D- ADDRESS OF THE EMPLOYER-

STATE-
DISTRICT-
PIN CODE-
E- EMAIL-
F- PHONE NO-
G- MOBILE NO-
11- DETAILS OF NOMINEE
NAME-
RELATIONSHIP WITH IP-
ADDRESS OF NOMINEE- STATE-
DISTRICT-
PIN CODE-
ID PROOF NO- PHONE NO-
IS NOMINEE A FAMILY MEMBER:- YES/NO MOB. NO-
12- FAMILY DETAILS-
Whether
Relationship Residing
S.NO Name Date of Birth with the with
employee Him/Her If NO-State Place of Residence Id Proof No-
PLACE STATE
1-
2-
3-
4-
5-
6-
13- BANK ACCOUNT DETAIL
ACCOUNT NO-
TYPE OF ACCOUNT-
NAME OF BANK- MICR CODE-
NAME OF BRANCH- IFSC CODE-

DATE- SIGNATURE

DISPENCARY ALLOCATION
STATE :-
DISTRICT:-
PREFFERED LOCATION:-

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NOTE-
ID AND ADDRESS PROOF COPY WITH SIGN

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