Emp Code Name / Name as per Aadhaar Records:*

Email ID
Anshul Mishra cse.anshul@gmail.com
Name of Father/ Husbund
Relation with Member
Date of Birth:* Aadhar No. *Marital Status:*

Anoop Mishra Father 8/1/1998 649947580014 Single

Gender:* Present Address with Dist, PIN & State * Mobile No.

Male 218, ward no.6, shahgarh dist sagar, 470339, Madhya Pradesh 8819804060
 Personal E-Mail Permanent Address with Dist, PIN & State *

cse.anshul@gmail.com 218, ward no.6, shahgarh dist sagar, 470339, Madhya Pradesh
 Add Bank Account Details Of Insured Person

Account Number Type of Account * Name of Bank *Name of Branch

 Curren
t
Emplo
Account Details Of Insured Person
Dispensary Or yer's
IMP:
Particu
lars
MICR Code of the Bank/Bran IFSC Code of the Bank/Branch Date of
 Status
(Active
/inacti
ve)
of Nominee u/sDate
71 of ESI Act 1948/Rule 56(2) of ESI (Central) Rules,1950 for Payment of Cash Benefit in the Event of Death ) Family
of
Relation
leavin
ship
g if Name / NDOB* WhetherMobile
r NName of family member DOB *
with
applica
I.P :*
ble
 Family Members Details Status

Relation with I.P.Whether

* resideing with him/herAddress
? of Nominee
IP NO Remarks