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