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EMPLOYEES STATE INSURANCE CORPORATION REG. FORM 2 ADDITION/ DELETION IN FAMILY DECLARATION FORM Regulation 15 B Name of the Insured Person Insurance No. I declare that the person/ persons whose particulars are given below has/ have now become/ ceased to be member s of my family. Name of IMP/Disp. attached. State I hereby declare that the particulars given above are true to the best of my knowledge and belief. Necessary changes may kindly be made in my Declaration Form submitted earlier. Passport size photographs of the members who are added to family is/ are enclosed. Place. Signature/thumb impression of the employee Date. Sl* No* Name Date of Birth Reason s for change date Relationship with the Insured Person Whether residing him/her or not state Yes No If no where Distt. Name of IMP/Disp* attached* State I hereby declare that the particulars given above are true to the best of my knowledge and belief* Necessary changes may kindly be made in my Declaration Form submitted earlier. Passport size photographs of the members who are added to family is/ are enclosed* Place. Signature/thumb impression of the employee Date. Particulars of the Employer - Name in Block Letters Address. Countersignature of the employer Code No*. Designation with Rubber Stamp Note Family means all or 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 who is wholly dependant on the earnings 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 a child who is infirm by reason of any physical or mental abnormality or injury and is wholly dependant on the earnings of the I. P. so long as the infirmity continues v dependant parents Please see Section 2 clause 11 of the ESI Act 1948 for details. Sl* No* Name Date of Birth Reason s for change date Relationship with the Insured Person Whether residing him/her or not state Yes No If no where Distt. Name of IMP/Disp* attached* State I hereby declare that the particulars given above are true to the best of my knowledge and belief* Necessary changes may kindly be made in my Declaration Form submitted earlier. Passport size photographs of the members who are added to family is/ are enclosed* Place. Signature/thumb impression of the employee Date. Particulars of the Employer - Name in Block Letters Address. Countersignature of the employer Code No*. Particulars of the Employer - Name in Block Letters Address. Countersignature of the employer Code No*. Designation with Rubber Stamp Note Family means all or any of the following relatives of an Insured Person namely i a spouse ii a minor legitimate or adopted child dependant upon the I. Designation with Rubber Stamp Note Family means all or 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 who is wholly dependant on the earnings 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 a child who is infirm by reason of any physical or mental abnormality or injury and is wholly dependant on the earnings of the I.

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