FORM 4 A

FAMILY IDENTITY CARD

(Regulation 95A)

 

 

Insurance No. ……………………………

 

Local Office/Regional Office………………………………………

to which attached

 

Sex: Male/Female

 

Name of the Insured Person………………………………………………

Address of family ………………………………………………

Dispensary of IP: ………………………………………………

 

Dispensary/Region of family: …………

 

PARTICULARS OF MEMBERS OF FAMILY AS GIVEN IN

THE DELCARATION FORM BY THE IP

 

S. NO.

NAME

DATE OF BIRTH

RELATIONSHIP WITH THE INSURED PERSON

IDENTIFICATION MARKS

 

 

 

 

 

 

 

 

Signature or Thumb impression of the Insured Person

(Rubber Seal of Issuing Office)

Signature/designation of Issuing Authority

 

 

 

 

 

Instructions:

  1. Report loss immediately to the Dispensary/Local Office to which Insured Person/family is attached
  2. Finder of this card may please return it to the address of family indicated above, post to ESI Local Office/Dispensary.

Family photograph duly attested (on reverse side.)