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.]