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Employees' State Insurance (General) Regulations, 1950

FORM 3: Return of Declaration Forms

[Regulation 14]

Name and address of the factory or establishment ..................................................................

Employer's Code No....................................................

    I send herewith the declaration forms in respect of the employees mentioned below. I hereby declare that every person employed as an employee within the meaning of section 2 (9) of the Employees' State Insurance Act, 1948, on ...............in this factory or establishment and in receipt of a remuneration not exceeding 47[Rs. 6500] per month has been included in this list (excepting only those in respect of whom declarations have been sent to the Corporation in the past).

Place.......................................                                                            

Signature......................................

Date .........................................                Designation ...................................

Sl. No.

Name of the employee

Distinguishing No. with the employer, if any

Fatherís /Husbandís name

Insurance No. allowed by the Corporation (to be entered at the appropriate office)

 

 

 

 

 

Enclosures:                                                                                                 

Signature .....................

Declaration Forms.........................................                                                Designation ................

Continuation Sheets ........................................





Employees'   State Insurance (General) Regulations, 1950 Back






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