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FORM 1A: FAMILY DECLARATION FORM Regulation 15A Name of the insured person .......................................... Insurance Number .......................................................
My Family Declaration Form may kindly be corrected accordingly. I hereby declare that the particulars above have been given by me and are true to the best of my knowledge and belief. I also undertake to intimate to the Corporation any changes in the membership of my family within 15 days of such changes having occurred. ....................................................... Signature/Thumb-impression of the insured person Date............................... Countersigned ....................................... Date .............................................. Designation ...................................... Name, address and code no. of employer..................................................................... Note: According to section 2, clause (1 1) of the Employees' State Insurance Act, 1948, "family" means all or any of the following relatives of an insured person, namely, (i) a spouse; (ii) minor legitimate or adopted child dependent upon the IP; (iii) a child who is wholly dependent on the earnings of the IP and who is-(a) receiving education, till he or she attains the age of 21 years, (b) an unmarried daughter; (iv) a child who is infirm by reason of any physical or mental abnormality or injury and is wholly dependent on the earnings of the IP, so long as the infirmity continues; (v) dependent parents. | |||||||||||||||
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