Discover a sample and content of an employee state insurance corporation temporary identity certificate form.

Sample employees state insurance corporation temporary identity certificate form

To join the employees state insurance scheme, the workers are required to fill a declaration form so that they can be issued with a temporary identification certificate (TIC) that has a validity of three months after which they are issued with a permanent identity card. It is after filling the form that the employee is given a registration number.

The insurance scheme is meant for Indian workers earning less than $ 230 in a month. The contribution of 6.5% of the employee’s salary is shared between the employer at 4.75% and employee at 1.75%.

The Employees State Insurance Corporation temporary identity certificate form contains

Employee details. These comprise of the employee’s name, the name of the husband/father, marital status, gender, age, date of birth and their address.

Employer details. The information about the employer, current and past, appears here. It includes employer’s code number, name and address.

Nominee details. A nominee is a person to whom benefits can be paid in the event that a person dies. This section contains the name of the nominee, age, address, and relationship with the insured person.

Family particulars of the person insured. This section has the name, date of birth, relationship with the insured and whether the person is residing with the insured.

Declaration. The insured person declares that the information provided in the form is true to the best of their knowledge and that they will inform the corporation in case there are any changes in family membership in 15 days.

Signatures. The employee insured and the employer sign the form.

Sample form

Employees State Insurance Corporation temporary identity certificate form- declaration form 1

Employee name:




Name of Father/Husband




Marital Status


Date of birth


Present Address


Present Address






Employer Details

Current Employer


Previous Employer


Employers code No


Employers Code No


Date of Appointment


Previous Insurance No


Name of Employer


Name of Employer






Nominee details under section 71 of Employee’s State Insurance Act 1948 and section 56(2) of ESI (Central) Rules, for payment of any benefit due in the event of the insured person’s death.

Name of Nominee […]

Relationship […]

Age […]

Address […]

Family particulars of insured person



Date of Birth

Relationship with Insured

Whether residing with insured person

















I declare that the information I have given is correct to the best of my knowledge and belief. I will inform the corporation of any changes in my family membership within 15 days of the change.

Signature or thumb impression of employee […]

Counter signature of employer […]

Date of signing the form […]


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