Employees’ State Insurance (General) Regulations, 1950

FORM 4A : Family Identity Card

[Regulation 95A]

Insurance No.........................................

Name of insured person..................................................

Sex..................................

Son/daughter/wife of.................................................

Address..........................................................................................................................................

Dispensary.............................................................................................

PARTICULARS OF MEMBERS OF FAMILY

Sl. No.	Name	Date of birth	Relationship with the insured person	Identification marks
1
2

Prepared by:

Signature or thumb-impression

of the insured person