EMPLOYEES' STATE INSURANCE CORPORATION

e-Pehchan Card

Insured Person :    

Insurance No. :      

Date of Registration :   30/11/-0001

YOUR REGISTRATION DETAILS

 

Employee Name:

Type of Disability :

None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Father / Husband:

Date of Birth :

01/01/1970

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status :

Unmarried

Gender :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Present Address :

 

,,Dist:,

 

Permanent Address :

 

,,Dist:,

 

 

 

 

   ,

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dispensary / IMP for IP :

Dispensary / IMP for Family:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UHID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Employer Details

 

 

 

 

First Employer Details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer's Code No. :

Employer's Code No. :

None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sub Unit's Code No. :

None

Sub Unit's Code No. :

None

 

 

Date of Appointment :

30/11/-0001

First Insurance No. :

None

 

 

Name of Employer :

Name of Employer :

None

 

 

Address of Employer :

  ,
  Dist:
 

Address of Employer :

None

 

 

Family Details:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

Relationship

 

Date of Birth

UHID

 

Whether Residing

 

State

 

District

 

 

 

 

with the

 

 

 

 

 

with Insured Person

 

 

 

 

 

 

 

 

Employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nominee Details:

Name of Nominee

Relationship with IP

Percentage

Address of Nominee

Other

100

A,Dist:

 

 

 

 

 

 

 

Documents Uploaded:

none

Signature / LTI of Registered Employee / IP :

Mobile Number :   

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

 

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.Employer to please affix employee and his family photo here and attest with official stamp across .

Signature / Stamp of ESIC Officer / Employer