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ESIC Declaration Form

This ESIC declaration form is an internal company form that collects the details HR needs to register an eligible employee under ESI, including any existing IP number, family members and preferred dispensary. It is not an official ESIC form; the official registration is completed on the ESIC portal.

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[Company Logo][Company Name]

ESIC DECLARATION FORM (INTERNAL)

Employee Name:: [Employee Name]
Employee ID:: [Employee ID]
Date of Joining:: [Date of Joining]
ESIC Employer Code:: [Code]

Note: This is an internal company form. Official registration will be completed by HR on the ESIC portal.

1. Eligibility

Gross monthly wages: ₹[Amount]
Covered under ESI (Yes / No – to be filled by HR)

2. Previous ESI Coverage

Were you covered under ESI earlier? (Yes / No)
Existing IP Number
Previous Employer Name and Code

3. Personal Details

Name
Father's / Husband's Name
Date of Birth
Marital Status
Present Address
Permanent Address
Mobile Number
Aadhaar (last 4 digits / masked copy)

4. Family Members (for medical benefit)

Name	Relationship	Date of Birth	Residing with Employee (Yes / No)	Town / City if Not Residing
[Name]	[Relationship]	[DD/MM/YYYY]	[Yes / No]	[City]
[Name]	[Relationship]	[DD/MM/YYYY]	[Yes / No]	[City]
[Name]	[Relationship]	[DD/MM/YYYY]	[Yes / No]	[City]

5. Dispensary Preference

Preferred dispensary for self
Preferred dispensary for family

6. HR – Official Registration Status

Registered on ESIC portal
IP number communicated to employee
e-Pehchan card / registration slip given
Contribution set in payroll

Declaration

I declare that the above particulars are true. I understand that my ESI contribution will be deducted from my wages as per law and that HR will complete my official registration on the ESIC portal using these details.

Signature of Employee
[Employee Name]
Date: [Date]
Place: [Work Location]

Verified by
[HR Name]
HR Department, [Company Name]
Date: [Date]

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What this template includes

Gross monthly wage check against ESI eligibility
Existing IP number to avoid duplicate registration
Family members for medical benefit
Preferred dispensary and branch office
Contribution explanation (0.75% employee, 3.25% employer)
Status of official portal registration and e-Pehchan card

When to use it

At joining, for employees whose wages fall within the ESI limit (currently up to ₹21,000 a month)
When an existing employee's wages come within ESI coverage
When a joiner already has an IP number from a previous employer
When family details change for ESI benefits

How to customise this template

1Add your ESIC employer code
2List nearby dispensaries for employees to choose from
3Remove for establishments not covered by ESI
4Track registration and card issue date

HR tips

Ask every joiner for an existing IP number first
Register eligible employees promptly as required by ESIC rules
Explain how to use ESI medical benefits
Update family details after marriage or childbirth

This is an internal company declaration form and is not a copy of any official government form. The official ESIC registration and any required declarations must be completed on the ESIC portal. Check current ESI rules and Labour Code provisions for coverage and timelines.

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Frequently asked questions

Who is eligible for ESIC?+

Employees of covered establishments earning up to ₹21,000 a month in wages are generally covered. Contributions are 0.75% by the employee and 3.25% by the employer.

Is this the official ESIC form?+

No. It is an internal form to collect details. Registration is completed by the employer on the ESIC portal.

What if I already have an ESIC IP number?+

Give it to HR so you are linked to the same number instead of being registered again.

All 50 joining & new employee documents →

[Company Logo][Company Name]

NOMINEE DECLARATION FORM (COMPANY DUES)

Employee Name:: [Employee Name]
Employee ID:: [Employee ID]
Designation:: [Designation]
Date of Joining:: [Date of Joining]

1. Scope of Nomination

This nomination covers amounts payable by [Company Name] in the event of my death while in service, including unpaid salary, leave encashment, pending reimbursements, performance bonus or incentive due, and any other company benefit not covered by a separate statutory nomination.

2. Nominee Details

Nominee Name	Relationship	Date of Birth	Address	Share (%)
[Nominee Name]	[Relationship]	[DD/MM/YYYY]	[Address]	[%]
[Nominee Name]	[Relationship]	[DD/MM/YYYY]	[Address]	[%]
[Nominee Name]	[Relationship]	[DD/MM/YYYY]	[Address]	[%]

3. Guardian Details (if any nominee is a minor)

Form · Word

Employee Nominee Declaration Form

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[Company Logo][Company Name]
PAN DECLARATION FORM
Employee Name:
[Employee Name]
Employee ID:
[Employee ID]
Financial Year:
[YYYY-YY]
Section A: PAN Details
PAN
Name exactly as on PAN
Father's Name as on PAN
Date of Birth as on PAN
PAN linked with Aadhaar (Yes / No / Not sure)
Section B: If PAN Is Not Yet Available
Date of PAN Application
Acknowledgement Number
Expected Date of Receipt
Section C: Name Difference (if any)
Form · Word
PAN Declaration Form
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[Company Logo][Company Name]
AADHAAR DECLARATION AND CONSENT FORM
Employee Name:
[Employee Name]
Employee ID:
[Employee ID]
Date:
[Date]
1. Aadhaar Details
Name as on Aadhaar
Aadhaar (last 4 digits only): XXXX XXXX [Last 4 Digits]
Copy submitted (Masked copy / Not submitted)
Mobile number linked to Aadhaar (Yes / No)
2. Purpose of Collection (tick what applies)
- Linking with UAN / EPF records
- Identity verification at joining
- Other purpose: [Specify]
3. Alternate Identity Document (if Aadhaar not provided)
Form · Word
Aadhaar Declaration Form
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PAN
Name exactly as on PAN
Father's Name as on PAN
Date of Birth as on PAN
PAN linked with Aadhaar (Yes / No / Not sure)

Date of PAN Application
Acknowledgement Number
Expected Date of Receipt

Name as on Aadhaar
Aadhaar (last 4 digits only): XXXX XXXX [Last 4 Digits]
Copy submitted (Masked copy / Not submitted)
Mobile number linked to Aadhaar (Yes / No)

[Company Logo][Company Name]

UAN DECLARATION FORM (INTERNAL)

Employee Name:: [Employee Name]
Employee ID:: [Employee ID]
Date of Joining:: [Date of Joining]
Establishment:: [Company Name]

Note: This is an internal company declaration. The official EPFO forms and online processes will also be completed where required.

A. Previous PF Membership

Were you a member of PF earlier? (Yes / No)
Do you have a UAN? (Yes / No)
UAN (if Yes)
Is the UAN activated on the member portal? (Yes / No)
Do you have more than one UAN? (Yes / No) – give details

B. Previous Employment PF History

Previous Employer	PF Member ID	Date of Joining	Date of Exit	PF Settled / Not Settled
[Employer]	[Member ID]	[DD/MM/YYYY]	[DD/MM/YYYY]	[Status]
[Employer]	[Member ID]	[DD/MM/YYYY]	[DD/MM/YYYY]	[Status]
[Employer]	[Member ID]	[DD/MM/YYYY]	[DD/MM/YYYY]	[Status]

Form · Word

UAN Declaration Form

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[Company Logo][Company Name]

FAMILY DETAILS DECLARATION FORM

Employee Name:: [Employee Name]
Employee ID:: [Employee ID]
Department:: [Department]

1. Immediate Family

Name	Relationship	Date of Birth / Age	Occupation	City
[Name]	Father	[Age]	[Occupation]	[City]
[Name]	Mother	[Age]	[Occupation]	[City]
[Name]	Spouse	[Age]	[Occupation]	[City]
[Name]	Child	[Age]	[Occupation]	[City]
[Name]	Sibling	[Age]	[Occupation]	[City]

2. Relatives Working in [Company Name] or Group Companies

Name	Relationship	Department	Designation
[Name]	[Relationship]	[Department]	[Designation]
[Name]	[Relationship]	[Department]	[Designation]

3. Relatives Linked to Vendors, Customers or Competitors

Form · Word

Family Details Declaration Form

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[Company Logo][Company Name]

DEPENDENTS DECLARATION FORM

Employee Name:: [Employee Name]
Employee ID:: [Employee ID]
Policy Year:: [YYYY-YY]
Action:: New enrolment / Addition / Deletion

1. Benefits Covered by This Declaration

Group medical insurance
Group personal accident (family floater, if any)
Other dependant benefit: [Specify]

2. Dependant Details

Name	Relationship	Date of Birth	Gender	Financially Dependent (Yes / No)	Other Health Cover (Yes / No)
[Name]	Spouse	[DD/MM/YYYY]	[Gender]	[Yes / No]	[Yes / No]
[Name]	Child	[DD/MM/YYYY]	[Gender]	[Yes / No]	[Yes / No]
[Name]	Child	[DD/MM/YYYY]	[Gender]	[Yes / No]	[Yes / No]
[Name]	Parent / Parent-in-law	[DD/MM/YYYY]	[Gender]	[Yes / No]	[Yes / No]

3. Mid-Year Change (if applicable)

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Dependents Declaration Form

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[Company Logo][Company Name]
NEW EMPLOYEE JOINING FORM
Company:
[Company Name]
Employee ID:
[Employee ID]
Date of Joining:
[Date of Joining]
Please fill all sections in capital letters and attach self-attested copies of the documents listed in Section 7. Paste a recent passport-size photograph in the box provided.
1. Personal Details
Full Name (as per PAN)
Father's / Spouse's Name
Date of Birth (DD/MM/YYYY)
Gender
Marital Status
Blood Group
Nationality
Mobile Number
Personal Email ID
Aadhaar (last 4 digits / masked copy)
2. Address
Current Address with PIN Code
Permanent Address with PIN Code
Years at Current Address
Form · Word
New Employee Joining Form
Download .docx
[Company Logo][Company Name]
NEW EMPLOYEE INFORMATION FORM
Company:
[Company Name]
Expected Date of Joining:
[Date of Joining]
Section 1: Basic Information
Full Name
Preferred Name (for email and ID card)
Mobile Number
Personal Email ID
City of Residence
Section 2: Role Information (to be pre-filled by HR)
Designation [Designation]
Department [Department]
Reporting Manager [Reporting Manager]
Work Location [Work Location]
Work Pattern (Office / Hybrid / Remote / Shift)
Section 3: IT and Access Requirements
Form · Word
New Employee Information Form
Download .docx

Full Name (as per PAN)
Father's / Spouse's Name
Date of Birth (DD/MM/YYYY)
Gender
Marital Status
Blood Group
Nationality
Mobile Number
Personal Email ID
Aadhaar (last 4 digits / masked copy)

Current Address with PIN Code
Permanent Address with PIN Code
Years at Current Address

Full Name
Preferred Name (for email and ID card)
Mobile Number
Personal Email ID
City of Residence

Designation	[Designation]
Department	[Department]
Reporting Manager	[Reporting Manager]
Work Location	[Work Location]
Work Pattern (Office / Hybrid / Remote / Shift)

ESIC Declaration Form

Preview of the form

1. Eligibility

2. Previous ESI Coverage

3. Personal Details

4. Family Members (for medical benefit)

5. Dispensary Preference

6. HR – Official Registration Status

Declaration

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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