FOR EMPLOYEES REGISTRATION FORM
Insured Person's Particulars (BELOW MENTIONED INFORMATI
Is IP Disabled:*
1.(b) Type of Disability:
1.(c) Select Certificate:
2. Name:*
3. Name of* (FATHER)
4. Date of Birth:*
5. Marital Status:* (UNMARRIED/ MARRIED/ WIDOW/
WIDOWER)
6. Gender:* (M/ F/ TG)
7. Present Address
Address :*
State:*
District:*
Pin Code:
Mobile No.*:
Email:
8. Permanent Address
Address :*
State:*
District:*
Pin Code:
Mobile No.*:
Email:
9 a. Dispensary Or IMP or mEUD For IP:*
State:
District:
Name of ESIC Dispensary/ IMP/ mEUD For IP:*
9 b. Dispensary Or IMP or mEUD for Family Members:*
State:
District:
Name of ESIC Dispensary/ IMP/ mEUD For Family Members:*
10. Current Employer's Particulars
Date of Appointment:* (DOJ)
11.(a) Have Previous Employer:
11.(b) In case of any Previous employment please fill up the
details below:
Employer's Code No.:
Previous Insurance No.:
Name of the Employer:*
Address of the Employer
State:
District:
Pin Code:
12. Details of Nominee :*
Name :*
Date of Birth :*
Relationship with Insured Person :*
Address of Nominee
Address :*
State :*
District :*
Pincode :
Is Nominee a Family Member :
13. Family Particulars of Insured Person: (SPOUSE/DEPENDENT
FATHER/ DEPENDENT MOTHER/ MINOR DEPENDENT SON/
DEPENDENT UNMARRIED DAUGHTER)
Name*
Date of Birth*
Relationship with the Employee*
Gender:* (M/ F/ TG)
Whether Residing with Him / Her?
14. Details of Bank Accounts of Insured Person:
Account Number*
Type Of Account* (CURRENT/ OTHERS/ SAVING)
Name Of Bank*
Name Of Branch*
MICR Code of the Bank/Branch
IFSC Code of the Bank/Branch*
NOTE :- * Required Fields (all the required fields
FOR EMPLOYEES REGISTRATION FORM 1
Particulars (BELOW MENTIONED INFORMATIONS ARE REQUIRED)
NO
Tazzamul Shafique
Sadullah Ahmed
10/2/1996
Unmarried
Male
House No. 14, Pragati Path, Chandan Nagar, Bhetapara, Guwahati
Assam
Kamrup (M)
781028
7399694610
tshafique56@gmail.com
do
Assam
Kamrup (M)
ESIC Dispensary Dispur
2/15/1996
Sadullah Ahmed
3/1/1970
Father
House No. 14, Pragati Path, Chandan Nagar, Bhetapara, Guwahati
Assam
Kamrup (M)
781028
Yes
Sadullah Ahmed Jahanara Begum X
3/1/1970 8/31/1976 00-00-0000
Father Mother
M F
Yes Yes
20268030338
SAVING
SBI
IIBM KHANAPARA
SBIN0010669
d Fields (all the required fields need to be filed up)
