Download ESIC FORM 1A FAMILY DECLARATION FORM

Download ESIC FORM 1A

 Download ESIC FORM 1A FAMILY DECLARATION FORM

As per ESIC Regulation 15A. Registration of families

On the issue of notification under regulation 95A, specifying the date from which the famAily of an insured person shall also be entitled to medical benefit under the Act, every insured person who has not furnished the particulars of his family at the time of his registration under the Act, shall furnish to the employer correct particulars [along with their photographs] in respect of his family in Form 1A. The employer shall enter the particulars in the form and obtain the signature or the thumb-impression of such person and complete the form as indicated thereon and send it to the appropriate office within 10 days of the date on which the particulars were furnished.

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