ESI PF Gratuity

7/29/2019 ESI PF Gratuity

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Name XYZ

F Name YZX

Address ABC 390000

Office Address CBA 390000

Phone

DOJ 6/1/2009

DOB 7/7/1981

Desi OPERATOR

Dept PRODUCTION

Marital UNMARRIED

Sex MALE

Religon Hindu

Name of the nomine OBC

Relaction FATHER

Birthdate Nominee 6/14/1948

Age 61

Dispensary D-15

PF # 814


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6/1/2009 6/14/1948

61


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(G.P.V.) --- Y-1531-20,000-1-2006

1. Insurance No.

Sex

MALE

Pin Code Pin Code

Counter Signature by the employer

r

Signature with seal Signature/ T.I of IP

FAMILY PARTICULARS OF INSURED PERSON

Yes No Town St

1

2

3

4

5

6

7

8

Name

Validity

Date

(Space for Photograph)

Branch Office XYZ

Relationship

Dispensary D-15

I Hereby declare that the particulars given by me are correct to the best of my knowledge and belief, I undertake to intima

corporation any changes in the membership of my family within 15 days of such change.

YZXName & Address of the employer

Telephone

No & E-mail

Address

0

c) Name & Address of the employer with

Telephone No & E-mail Address

12.In case of any pervious employment pl

fill up the details as under :-Present Address

ABC ABC

Permanent Address

3. Father's /

Husband's Name

Date of Birth

xxxxxx

Date of Appointment

CBADDMMYYYY

7/7/1981 UNMARRIED

Maritail Status

DECLARATION FORM

To be filled in only if the employee after reading instruction overlief. Two Postcard size photographs are to be attached

this form. This form is free of cost.

6/1/2009

(A) INSURED PERSON'S PARTICULARS (B) EMPLOYER'S PARTICULARS

Employer's Code No.

2. Name

(In Block capital)

Form 1

XYZ

Name

0

390000

Address

a) Pervious ins. No.

b) Emplrs. Code No.

NIL

NIL

Details of the Nominee u/s 71 of ESI Act 1948/ Rule 56(2) of ESI (Central Rules, 1950 for paymemt of cash benefit in the

of death.

390000

ABCOBC FATHER

NIL

Telephone No &

E-mail Address

Relationship

with the

Employee

Whether residing with

him/her?

If 'NO' state plac

ResidenceName

Date of

Birth/ age

as on date

Sr No.

r ----------------------------

------------------------------------------------------------------------------------------------------------------------------------------------------------------

Dispensaryxxxxxx

xxxxxx CBAEmployeer's code No.& Address

D-15Branch Office

_________________________________

1. Insurance No.Date of

Appointment6/1/2009

XYZ


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1

2

3 Identity card is Non- transferable.

4 Loss of Identity card be reported to the employer / Branch Manager immediately.

5 Submission of false infoemation attacts pencil action under section of 84 of ESI Act, 1984.

6 This form duly filled in must reach the concerned Branch Office eithin 10 days of appointment of an Employee

7

8 For more details visit website of ESIC at www.esic.org. in or contact Regional office or Branch Office.

1. Date of allotment of Ins. No




Yes No Town State

1

2

3

45

6

7

8

As an Insured person you and your dependent family members are entitled to full medical

care. The other benefit in cash include (1) Sickness benefit (2) Temporary disablement

benefit (3) Permanent disablement benefit (4) Dependence Benefit and (5) Materni

For Branch Office Use Only

0

If 'NO' state place of

Residence

0

0

0

0

INSTRUCTIONS

Submition of Form-I is governed by regulation 11 & 12 of ESI (General ) Regulation 1950.

"Family means all of any of the following relatives of an Insured Person Namely:-

(i)a Spouse (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a child whois wholly dependence on the earning of the I.P. and who is (a) receiving education, till he or

she attains the age of 21 years (b) an unmarried daughter; (iv)

Sr No. Name

Date of Birth/ age

as on date of

form filling

Relationship

with the

Employee

Whether residing with him/her?


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I hereby nominate the person(s)/ cancel the nomination made by me, previously and nominate the person (s)

mentioned below to receive the amount standing to my credit in the Employee's Provident Fund, in the

event of my death.

age of

nomi- minor, name and

nee(s) address of the

guardian who may

receive the amount

during the minority of

the nominee

4

1. * Certified that I have no family as defined in para 2(g) of the Employee's Provident Fund scheme, 1952 and

should I acquire a family hereafter the above nomination should be deemed as canelled.

2. * Certified that my father/mother is/are depeneded upon me.

* Strike out whichever is not applicable

r

Signature/or thump impression of the subscriber

Address

6. Account No.

Permanent Address

ABC

Temporary Address

GJ/21478/ 814

Employee's Pension Scheme, 1955)

ABC

PART - A (E.P.F.)

61 100%

relationship with of accumulations in

Nominees the member Provident Fund to be

Form-2 (Revised)

NOMINATION AND DECLARATION FORM

FOR UNEXEMPTED/EXEMPTED ESTABLISHMENT

(Paragraph 33 and 61 (1) of the Employee's Provident Fund Scheme 1952 & Paragraph 13 of the

Declaration and Nomination for under the Employee's Provident Funds and

Employee's Pension Schemes

6/1/2009Date of Joining

Total amount of share If the nominee is a

paid to each nominee

Nominee /

4. Sex MALE

5. Marital Status UNMARRIED

Name of the

FATHER

1. Name (In block

letters)

2. Father's /

Husband's Name YZX

Nominee's

7/7/1981

XYZ

3. Date of Birth

NIL

6

1 2 3 5

OBC ABC


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widow / children pension in the event of my premature death.

Serial No. Name of the family member Age

1 4

12

3

** Certified that I have no family as defined in para 2(b) of the Employee's Pension Scheme, 1995 and should I

acquire a family hereafter I shall furnish particulars thereon in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a)

(I) & (ii) in the event of the death without leaving any eligible family member for receiving pension.

Date :

r

* Strike out whichever is not applicable

Certified that the above declaration and nomination has been signed/thump impressed before me by

Shri/Smt.Kum. employed in my

establishment after he/she has the entries/the entries have been read over to him/her by me and got

confirmed by him/her.

Place:

Date :

Name & Address of the Factory / Establishment Signature of the Employer or other

and Rubber Stamp thereof authorised officer of the establishment

6/1/2009

6/1/2009

xxxxx

CBA

ABC

2 3 5

Not Applicable

PART - B (E.P.S.)

(PARA - 18)

I hereby furnished below particulars of the members of my family who would be eligible to receive

Address Relationship with the member

Signature of thump impression

of the Subscriber

CERTIFICATE BY EMPLOYER

XYZ

Name & Address of the Nominee Date of Birth Relationship with member

OBC

6/14/1948 FATHER


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To:

1. Shri/Shrimati/Kumari

Whose particulars are given in the statement below, hereby nominate the persons's mentioned below to

receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my

death before that amount has become payable, or having become payable, has not been paid and direct that

the said amount of gratuity shall be paid in proportion indicated against the name (s) of the nominee (s).

2. I herby certify that the person(s) mentioned is a/are member (s) of my family within the meaning of

clause (h) of section 2 of the Payment of Gratuity Act, 1972.

3. I hereby certify that I have no family within the meaning of clause (h) of section (2) of the said Act.

4. (a) My father/mother/parents is/are not dependent on me.(b) My husband's father/mother/parents is/are not dependnet on my husband

5. I have excluded my husband from my family by a notice dated the

to the controlling authority in terms of the provision to clause (h) of section 2 of the said Act.

6. Nomination made herein invalidates my previous nominee(s)

No. Name in full with address Relationship with Age of Proportion by which the

of nomine (s) the employee nominee gratuity will be shared

OBC

ABC

Form `F'(See Sub-rule (1) of Rule 6)

NOMINATION

XYZ

CBA

FATHER 61 100%

Nominees

1


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1. Name of employee in full:

2. Sex :

3. Religion :

4. Whether unmarried/ married/ widow / widower

5. Department/ Branch/ Section/ where employed

6. Post held with Ticket or Serial No. if any

7. Date of address

8. Permanent address

Village Thana Sub-Division

Post office District State

Place

Date r

Signature/Thump impression of the employee

Name in full and full address of witnesses Signature of witnesses

1

2

Place VADODARA

Date 6/1/2009

Certified that the particulars of the above nomination have been verified & recorded in this establishment.

Registration No. GR.

Date 6/1/2009

Employer's Signature & Designation

Name & Address of Establishment or Rubber Stamp

Received the duplicate copy of nomination in form `F' filed by me and duly certified by the employer.

r

UNMARRIED

PRODUCTION

OPERATOR

6/1/2009

ACKNOWLEDGEMENT BY EMPLOYER

ABC

DECLARATION BY THE WITNESSES

Nomination Signed/thumb impressed before me

CERTIFICATE BY THE EMPLOYER

STATEMENT

XYZ

MALE

Hindu

Documents

ESI PF Gratuity