temporary identity certificate

1
EMPLOYEES STATE INSURANCE CORPORATION TEMPORARY IDENTITY CERTIFICATE Insured Person : YOUR REGISTRATION DETAILS Employee Name : Type of Disability : Name of Father / Husband: Date of Birth : Marital Status : Gender : Present Address : Permanent Address : Current Employer Details Employer's Code No. : Employer's Code No. : Date of Appointment : Previous Insurance No. : Name of Employer : Address of Employer : Name of Employer : Dispensary / IMP : Address of Employer : None N.VENKATESWARA RAO 26/01/1989 Unmarried F Bhavani Nagalla,D.No. 6-51,S.E.R CENTER,VIJAYAWADA,Dist:Krishna,Andhra Pradesh,520118 Bhavani Nagalla,D.No. 6-51,S.E.R CENTER,VIJAYAWADA,Dist:Krishna,Andhra Pradesh,520118 None 52000170240000911 Previous Employer Details None 02/08/2012 Ananth Technologies Ltd Plot No.39,ANANTH INFO PARK, HI-TEC CITY, PHASE-II,MADHAPUR,Dist:HyderabadAndh ra Pradesh500081 None None None Insurance No : Date of Registration : 5209363347 17/09/2012 Sub Unit's Code No. : Sub Unit's Code No. : None None Family Details: Bhavani Nagalla Bhavani Nagalla Name Relationship with the Employe Date of Birth Whether Residing with I State District --- --- --- --- --- --- Documents Uploaded: none Please Verify the Above Particulars. Please Notify Your Employer or in the Branch Office Address Below Incase of Any Information Found Incorrect. To get permanent ID card, employee is requested to visit the following branch office to get biometric & photo captured by this date 02/10/2012 , in the Below Branch Office : BO- Sanathnagar,Plot.No.54/A,Sundernagar Model Colony,Erragadda, Hyderabad.500 038 Tel. 04023701714, or any nearest ESIC Bio-metric Camp Locations. Signature / LTI of Registered Employee / IP : Affix Your Family Photograph Here.(Attested and Stamped by Employer / ESIC Official) Mobile Number : NOTE: 1. Please Keep this Printout for Future Reference and Bring this Along with Your Photo ID Card for All Your Claim Benefits and Medical Benefits . 2. This Copy Should be Retained with You until the Biometric Card is Dispatched . 3. Employer to please affix employee and his family photo here and attest with official stamp across . Address of Nominee Percentage Relationship with IP Name of Nominee N.VENKATESWARA RAO Dependant father 100 ECR CENTRE,Prasadampadu,Vijayawada,Andhra PradeshDist:Krishna Nominee Details: Signature / Stamp of ESIC Officer / Employer

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Page 1: TEMPORARY IDENTITY CERTIFICATE

EMPLOYEES STATE INSURANCE CORPORATION

TEMPORARY IDENTITY CERTIFICATE

Insured Person :

YOUR REGISTRATION DETAILS

Employee Name : Type of Disability :

Name of Father / Husband: Date of Birth :

Marital Status : Gender :

Present Address : Permanent Address

:

Current Employer Details

Employer's Code No. : Employer's Code No. :

Date of Appointment : Previous Insurance No. :

Name of Employer :

Address of Employer :

Name of Employer :

Dispensary / IMP :

Address of Employer :

None

N.VENKATESWARA RAO 26/01/1989

Unmarried F

Bhavani Nagalla,D.No. 6-51,S.E.R

CENTER,VIJAYAWADA,Dist:Krishna,Andhra

Pradesh,520118

Bhavani Nagalla,D.No. 6-51,S.E.R

CENTER,VIJAYAWADA,Dist:Krishna,Andhra

Pradesh,520118None

52000170240000911

Previous Employer Details

None

02/08/2012

Ananth Technologies Ltd

Plot No.39,ANANTH INFO PARK, HI-TEC

CITY,

PHASE-II,MADHAPUR,Dist:HyderabadAndh

ra Pradesh500081

None

None

None

Insurance No :

Date of Registration :

5209363347

17/09/2012

Sub Unit's Code No. : Sub Unit's Code No. :None None

Family Details:

Bhavani Nagalla

Bhavani Nagalla

Name Relationship with the Employe Date of Birth Whether Residing with I State District

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

Documents Uploaded: none

Please Verify the Above Particulars.

Please Notify Your Employer or in the Branch Office Address Below Incase of Any Information Found Incorrect.

To get permanent ID card, employee is requested to visit the following branch office to get biometric & photo captured by this date

02/10/2012 , in the Below Branch Office : BO- Sanathnagar,Plot.No.54/A,Sundernagar Model Colony,Erragadda, Hyderabad.500 038

Tel. 04023701714, or any nearest ESIC Bio-metric Camp Locations.

Signature / LTI of Registered Employee / IP :Affix Your Family Photograph Here.(Attested and Stamped by Employer / ESIC Official)

Mobile Number :

NOTE:1. Please Keep this Printout for Future Reference and Bring this Along with Your Photo ID Card for All Your Claim Benefits and Medical Benefits .

2. This Copy Should be Retained with You until the Biometric Card is Dispatched .

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

Address of NomineePercentageRelationship with IPName of Nominee

N.VENKATESWARA RAO Dependant father 100 ECR CENTRE,Prasadampadu,Vijayawada,Andhra PradeshDist:Krishna

Nominee Details:

Signature / Stamp of ESIC Officer / Employer