EMPLOYEES' STATE INSURANCE CORPORATION

e-Pehchan Card

Insured Person : Pati Nagarjuna THIS CARD IS VALID up to 15/01/2017 *(If Aadhaar number is not entered)
Insurance No. : 5212741046 For extending the validity, please get the Aadhaar number of self and family
Date of Registration : 17/12/2016 seeded through Employer/staff of ESIC/IP portal or visit a Pehchan Camp
along with family for giving Bio-metrics/Photograph.

YOUR REGISTRATION DETAILS

Employee Name: Pati Nagarjuna Type of Disability : None

Name of Father / Husband: PATI VIJAYA BASKARA RAO Date of Birth : 25/03/1987

Marital Status : Unmarried Gender : Male

5-187,MEMMIDISTEEDY 5-187,MEMMIDISTEEDY
Present Address : Permanent Address :
STREET,PALAKODERU, STREET,PALAKODERU,
MANDALAM,VENDRA, WEST MANDALAM,VENDRA, WEST
GODAWARI,Dist:West Godawari,Andhra GODAWARI,Dist:West Godawari,Andhra
Pradesh,534210
Aadhaar : 709149556529 Aadhaar Status : Unverified

Dispensary / IMP : Sanathnagar-I, AP (ESIS Disp.)

Current Employer Details First Employer Details

Employer's Code No. : 53000178110001001 Employer's Code No. : None

Sub Unit's Code No. : 52530178110011001 Sub Unit's Code No. : None
Date of Appointment : 11/11/2016 First Insurance No. : None

Name of Employer : Shabari Telecable Network Pvt.Ltd Name of Employer : None

Plot No. 50 / 2, Road No. 2,Jupiter Colony,
Address of Employer : Address of Employer : None
Opp. SMR Complex,Near Diamond
Point,,Dist:HyderabadTelangana500011

Family Details:
Relationship Whether
Name Date of Birth State District Aadhaar Aadhaar Status
with the Residing with
Employee Insured Person
PATI VIJAYA Dependant father
23/04/1957
Andhra West
NA NA
No
BHASKARA RAO Pradesh Godawari

PATI SUSEELA Dependant mother

17/08/1963
Andhra West
NA NA
No
Pradesh Godawari

Nominee Details:
Name of Nominee Relationship with IP Percentage Address of Nominee Aadhaar Aadhaar Status
PATTI VIJAYA Dependant father SAME AS ABOVE,Andhra
100 NA NA
BASKARA RAO PradeshDist:West Godawari
Documents Uploaded:
none

Signature / LTI of Registered Employee / IP :

Affix Your Family Photograph Here.(Attested and Stamped by Employer / ESIC Official)

Mobile Number :

NOTE:
1. Please keep this printout for future reference and bring this along with your Photo ID for all your Claim Benefits and Medical Benefits.
2. This copy should be retained with you until the Pehchan Card is received.
3. Employer to please affix employee and his family photo here and attest with official stamp across .

* If Aadhaar number is present, this e-Pehchan Card is valid till IP is eligible for treatment.

Signature / Stamp of ESIC Officer / Employer