EMPLOYEES' STATE INSURANCE CORPORATION

e-Pehchan Card

Insured Person : Ashutosh Singh THIS CARD IS VALID up to 09/03/2017 *(If Aadhaar number is not entered)
Insurance No. : 3514680209 For extending the validity, please get the Aadhaar number of self and family
Date of Registration : 08/02/2017 seeded through Employer/staff of ESIC/IP portal or visit a Pehchan Camp
along with family for giving Bio-metrics/Photograph.

YOUR REGISTRATION DETAILS

Employee Name: Ashutosh Singh Type of Disability : None

Name of Father / Husband: MANAN RAY Date of Birth : 01/01/1991

Marital Status : Unmarried Gender : Male

SAIKRUPA BUILDING ROOM NO 202,,NEAR KORAM, SHIWAN, KROM, SIWAN,

Present Address : Permanent Address :
GAON DEVI MANDIR, GHANSOLI, NAVI BIHAR,Dist:Siwan,Bihar,841239
MUMBAI,,Dist:Thane,Maharashtra,400701

Aadhaar : 570036306992 Aadhaar Status : Unverified

Dispensary / IMP : None

Current Employer Details First Employer Details

Employer's Code No. : 35000377630000699 Employer's Code No. : None

Sub Unit's Code No. : None Sub Unit's Code No. : None
Date of Appointment : 30/01/2017 First Insurance No. : None

Name of Employer : PARTH FACADE SOLUTION PRIVATE Name of Employer : None

LIMITED SHANTI NAGAR, SECTOR
001-B,65,
Address of Employer : Address of Employer : None
NO.1,JAYDEEP CO HSG. SOC.,OPP. TMT
BUS STOP,,MIRA ROAD
(E),Dist:ThaneMaharashtra401107

Family Details:
Relationship Whether
Name Date of Birth State District Aadhaar Aadhaar Status
with the Residing with
Employee Insured Person
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Nominee Details:
Name of Nominee Relationship with IP Percentage Address of Nominee Aadhaar Aadhaar Status
MANAN RAY Dependant father SAME AS
100 NA NA
ABOVE,BiharDist:Siwan
Documents Uploaded:
none

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 for all your Claim Benefits and Medical Benefits.
2. This copy should be retained with you until the Pehchan Card is received.
3. Employer to please affix employee and his family photo here and attest with official stamp across .

* If Aadhaar number is present, this e-Pehchan Card is valid till IP is eligible for treatment.

Signature / Stamp of ESIC Officer / Employer