Employees’ State Insurance (General) Regulations, 1950
FORM 1B: Changes in Family Declaration Form
[Regulation 15B]
Name of the insured person.............................................
Insurance No ....................................................
I hereby declare that the person/persons whose particulars are given below has / have now become / ceased to be members of my family ..
Sl. No. | Name | Date of birth | Relationship with insured person | * Whether residing with him/her or not | Reasons for change |
I hereby declare that the particulars given above are true to the best of my knowledge and belief.
Signature/thumb impression of the insured person
Date................................
Countersigned ................................
Date .................................................
Designation .........................................
Name, address and code no. of the employer......................................................................
14 Note : According to section 2, clause (11) of the Employees' State Insurance Act, 1948, "family" means all or any of the following relatives of an insured person, (i) a spouse; (ii) a minor legitimate or adopted child dependent upon the IP; (iii) a child who is wholly dependent on the earnings of the IP 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 dependent on the earning of the IP, so long as the infirmity continues; (v) dependent parents.]