EMPLOYEES' STATE INSURANCE CORPORATION

e-Pehchan Card

PERSONAL DETAILS

Name of IP : ROMENDRA YADAV Insurance No. : 4118850561

Date of Birth : 21/06/1999 UHID : NA
Gender : Male UAN : NA
Mobile Number : 9131234772 ABHA : NA
Email ID : NA PHR Address : NA
Registration Date : 14/02/2023 Aadhaar : NA

REGISTRATION DETAILS

Marital Status : Unmarried Name of Father / : SHANKAR LAL YADAV

Husband
Type Of Disability : NA
Present Address : PANCHAYAT CHOUK, PO -JOBA, WARD Permanent Address : PANCHAYAT CHOUK, PO
-20,ACHHOLA,,MAHASAMUND,,Dist:Mah -JOBA, WARD
asamund,Chhattisgarh,493445 -20,ACHHOLA,,MAHASAMUN
D,,Dist:Mahasamund,Chhattisg
Dispensary / : Birgaon, CT (ESIS Disp.) Dispensary / Birgaon, CT (ESIS Disp.)
: arh,493445
IMP for IP IMP for Family

CURRENT EMPLOYER DETAILS

Employer's Code : 74000323360000503 Name of Employer : SRMB SRIJAN PRIVATE

No. LIMITED

Sub Unit's Code : 41410323360010503 Date of : 06/02/2023

No. Appointment

Address of : 7, KHETRA DAS LANE, KOLKATA - Branch Office : BO - Calcutta,3A/3B, Maharani

Employer 12,Dist:KolkataWest Bengal700012 Swarnamoyee Road,
Kolkata,700009

FAMILY DETAILS

Name Relation Date UHID/ABHA PHR UAN/ Is Residing State/District

with of Birth Address Aadhaar with IP
IP

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 NOMINEE DETAILS

UHID/
Name of Nominee Relation with IP Date of Birth Address of Nominee Percentage(%)
ABHA

PANCHAYAT CHOUK, PO
SHANKAR LAL Dependant father NA NA -JOBA, WARD 100
YADAV -20,ACHHOLA,,MAHASAMU
ND,,ChhattisgarhDist:Mahasa
mund493445

Affix Your Family Photograph Here. (Attested and Stamped by

Employer / ESIC Official)

Signature / LTI of Registered Employee / IP

Signature / Stamp of ESIC Officer / Employer

Note:
· This e-Pehchan card affixed with photograph of family & duly attested by the Employer/ESIC Staff shall be requested for
availing cash/medical benefit.
· e-Pehchan card is a proof of registration under ESI scheme. However eligibility for various benefits depends upon the
contribution conditions. For further information on eligibility to various Benefits, please visit- www.esic.in

Printed By (Employer/User Name) : SRMB SRIJAN PRIVATE LIMITED

IP Number : 4118850561
Address : PANCHAYAT CHOUK, PO -JOBA, WARD
-20,ACHHOLA,,MAHASAMUND,,Dist:Mahasamund,Chhattisgarh,493445
Date : 14/02/2023 7:05:52PM

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