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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





Employees'   State Insurance (General) Regulations, 1950 Back






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