JOINING KIT

Welcome to NetAmbit!

Name :

Designation :

Date of Joining : Employee Code:

Instructions
Please read the instructions carefully before filling up the form.

1. Fill up all the forms listed below in CAPITAL LETTERS with blue or black pen only.
2. Write “NA” where it‟s not applicable.
3. Make sure all the relevant documents are attached with the Joining Kit.

List of Forms

S.No. Forms
1 Employee Information Sheet
2 Educational Qualification / Experience Summary
3 Emergency Details
4 Code Of Conduct
5 Bank Updation Form
6 PF Form 2 [Nomination and Declaration Form]
7 New PF Form – 11 [Declaration Form]
8 Form of Gratuity
9 ESIC Form [If Applicable]
10 Insurance [Nomination and Declaration]

Signature________•____________

1/11
Joining Report - Netambit
 Please
EMPLOYEE INFORMATION SHEET paste your
Self-
attested
PERSONAL DATA FORM (Please fill in BLOCK LETTERS)
photograph

DESIGNATION (JOINING AS)

FIRST NAME

LAST NAME

DATE OF BIRTH PLACE OF BIRTH

GENDER (Male/Female) NATIONALITY

RELIGION MARITAL STATUS

PRESENT ADDRESS

PERMANENT ADDRESS

CONTACT # (RESIDENCE)

CONTACT # (MOBILE)

EMAIL ID

FAMILY DETAILS

MEMBERS NAME AGE OCCUPATION

FATHER

MOTHER

Signature________•____________

2/11
Joining Report - Netambit
EDUCATION QUALIFICATION

BOARD/ REGULAR/ YEAR OF % MAJOR

QUALIFICATION UNIVERSITY/ CORRESPOND PASSING MARKS SUBJECT
INSTITUTE ENCE
Board Regular/Corresp Year Of Major
Secondary School ondence Passing Subject

(X)
Board Regular/Corresp Year Of
Higher Secondary ondence Passing
School (10 + 2)

Graduation (If
pursuing, please
mention the year)

Post-Graduation (If
pursuing, please
mention the year)
Other
Course/Diploma

EXPERIENCE SUMMARY

PERIOD DESIGNATION GROSS REASON FOR

SALARY LEAVING
ORGANISATION DRAWN

FROM TO

Signature________•____________

3/11
Joining Report - Netambit
PAN NUMBER DETAILS (to be filled for salary 10,000 & above)

(If You Don‟t Have Pan No., Please apply for the Pan Card and Submit the acknowledgement Slip)

PAN NUMBER:

EMERGENCY DETAILS (Mandatory)

 Blood Group:

 Contact Person Name & Phone No. in case of Emergency:

Name:

DATE:

PLACE:

______________•______________
SIGNATURE OF EMPLOYEE

4/11
Joining Report - Netambit
 EMPLOYEE DECLARATION Self-attested
photograph of the
employee
To,

NetAmbit ValueFirst Services Pvt. Ltd.

A 83, Ground Floor, Sector -2, Noida-201301

I, S/o,D/o,W/o__ R/o dohereby solemnly affirm, undertake and declare as under:

1. Termination of Previous Employment'

2.
I hereby declare that I have resigned from the services of my previous employer and my last
working date with them was .

I hereby declare that I am undertaking full time employment with Company and not doing any
part time employment or involved in any type of business and will also not do during my
employment / association with Company.

Signature_________•___________

5/11
Joining Report - Netambit
2. 'Medical Fitness'

I hereby declare that I am medically fit & that I do not suffer from any serious illness or
infection or any other terminal or communicable/infectious disease.

3. 'No Criminal Record'

I hereby declare that I have no criminal record and I do not have any criminal legal cases or
investigations pending against me. I understand that I will be solely responsible, accountable
and liable for my previous issues with the previous employer including but not limited to
behavioral issues, mis commitments, misrepresentations, fraud, forgery, police and any
criminal cases.

4. ‘Non-Bankruptcy’

I hereby declare that I am Solvent and have never filed for Bankruptcy.

5. ‘Data Protection, Confidentiality and Secrecy’

I recognize, accept and agree that all tangible and intangible information obtained or disclosed
to me by Company’s clients, customers, including all details, documents, data,
business/clients, customers information and their practices and trade secrets (all of which are
hereinafter collectively referred to as "Confidential information") which may be communicated
to me shall be treated as absolutely confidential and I irrevocably agree and undertake to keep
the same as secret and confidential and shall not disclose the same, at all in whole or in part to
any person or persons (including legal entities) at any time or use nor shall allow the
Confidential Information' to be used for any purpose other than as may be necessary for the
due performance of my duties in the best interest of the Company.

I further undertake that upon demand or upon termination of my employment with the
Company, I shall immediately comply with all instructions regarding the disposition of any
confidential Information in my possession and undertake that I shall not accumulate
confidential information in any way or make use/mis-use/unauthorized use of confidential
information in future and even after termination of my employment/association with the
Company.

6. ‘Non-Solicitation or No-Poach of Employees’

I undertake, declare & agree that I shall not either directly or indirectly solicit, induce, recruit or
encourage any of Company's (including its affiliate companies) employees to leave their
employment, or take away such employees, or attempt to solicit, induce, recruit, encourage or
take away employees of Company, either for myself or for any other person or entity during the
tenure of employment with Company and for a period of one (1) year immediately following
the termination of the employee relationship with Company for any reason whatsoever,
whether with or without cause.

Signature ___________•____________

6/11
Joining Report - Netambit
7. ‘Authenticity of Information & documents’

I hereby declare that the information provided and representations made by me in my resume
and/ or other documents, declaration submitted during the interview process or otherwise are
correct, accurate & genuine. My selection is based on the assumption that my qualifications,
experience and other details are correct, accurate & genuine. I further declare that I have not
withheld any material information, including education qualifications, which would have
affected my appointment with the Company.

8. ‘Background Check’

The company may at its absolute discretion conduct background checks on the information
provided by me either directly OR through an authorized third party / or otherwise for obtaining
investigative employment screening report for employment including in connection with my
application for employment. This employment screening report will include but not limited to
educational verification, previous employments verification, ID & address verification, character
verification, general reputation, criminal records etc.

9. ‘No Relation and/or connection’

I hereby declare that I am not related, either directly or through my relative(s), to any Director,
Senior Management Person or any other employee of the Company and I am not in any way
connected with the Company under the provisions of the Companies Act, 1956 and any rules
and regulation made thereunder except as declared in writing.

10. Restraint on business

I hereby undertake that I shall not, during the period of my employment with the Company,
either personally or through any person including relative, company or through a partnership or
as a proprietor, shareholder, joint venture partner, collaborator, consultant, advisor, principal
contractor or sub-contractor, director, trustee, committee member:

a. be involved in any business activity which is not authorised by the

company(including resale);

b. be involved directly or indirectly in any business including that is identical to the

Business of the Company as is carried on from time to time including partners
associated with the Company or otherwise;

c. except on behalf of the Company, canvass or solicit business for services similar to
those being provided by the Company from any person who is a customer of the
Company or otherwise;

Signature ____________•___________

7/11
Joining Report - Netambit
 d. induce or attempt to induce any customer/client of the Company to cease to be a
customer/client, cancel business or otherwise interfere with the relationship between
such a customer/client and the Company (save and except actions taken during the
course of his employment with the Company in exercise of his power and authority as
an employee of the Company and in, what he reasonably believes to be, in the interest
of the Company).

11. ‘Forgery & Miscommunication / Misrepresentation’

I understand that I am joining a Company which is renowned in its area of business and have
earned enviable reputation in its business & is a name associated with quality and perfection. I
declare that during the period of my employment, I will not miscommunicate, misrepresent to
any of my company’s clients/customers anything which can have an impact on company’s
reputation in whatsoever way. I understand that due to my miscommunication,
misrepresentation the company may suffer a huge loss of reputation & goodwill which cannot
be compensated in terms of money only and company will have all rights to take appropriate
actions against me for such miscommunications/misrepresentations.

I understand that fake, forgery of documents or signatures or submission of any other fake
documents, details is a criminal offence and that I shall never do the same. The company will
have all rights to take appropriate actions against me for such act done by me.

12. ‘Business exclusively for the Company’

I declare that the Company has provided me with complete details of selling and marketing of
products/services of the Company. I further declare that I will not engage in any business other
than the business of the Company.

I declare that I’ll not collect/receive any cash from any client for & on behalf of the Company. I
understand that I am not authorized by the Company to collect/receive any cash from any
client/customer.

I declare that I will not offer any schemes, prices, offers (other than what I am authorized)
while making the said sale or market of any products/services to any clients/customers of the
Company. I further declare that I will not make any false promise or assurances regarding any
products/services either on behalf of my company or on behalf of the Principal Companies.

13. ‘Prohibition to use Mobile Phone/other phone’: (This clause is applicable only for
Telecaller/Tele Sales officer)

I declare that the Company has provided me with dedicated landline phones to make
Official call/use and as such I am prohibited to make any official call/use my own mobile
phone(s) /other phone except dedicated landline phones provided by the Company.

I declare that I am aware that as per the company policy the use of my own mobile phone
/other phone for making official calls in pre & post office hours of the Company to the existing
& prospective clients/customers of the Company is unauthorized and illegal. I declare that I will
not use my own mobile phone/other phone for official use.

Signature ___________•____________

8/11
Joining Report - Netambit
14. ‘Communication with the clients/customers of Company’

a) I hereby undertake & agree that I shall not contact/communicate with the clients/customers
of the Company through my personal e-mail id or any other personal means of electric
communication.

b) I further hereby undertake & agree that I shall not communicate & offer benefits/
incentives/discount to clients/customers of the Company which is not authorized and approved
by the Company.

In case of non-adherence of the above, I will be held liable to pay a penalty of Rs.
50,000/- to the Company in addition to loss of business, if any suffered by the Company.

15. ‘Company Mobile/ Other Phone Usage’

In case I have been given Company mobile phone/other phone as per policy of the Company, I
declare that I will not tamper/ damage in any manner whatsoever including tampering/
damaging the software/settings of the Mobile Phone/other phone provided to me by the
Company for official use. I also understand that in case the Mobile phone/other phone is being
found tampered/ damaged, the HR Dept. of the Company may take appropriate actions and in
case of a second /repeat offence of similar nature, I will be liable for a deduction of Rs. 500/-
plus the actual cost of repair of the Mobile Phone/other phone from my salary. I understand
that the IT Dept. of the Company will conduct a weekly inspection of the Mobile Phone/other
phone provided to me by the Company and I shall fully co-operate with the same. I declare
that I will not carry the Mobile Phone/other phone with me to my home and will submit the
same with the designated department before going to home/leaving office.

16. ‘Quality & Compliance’

I hereby undertake & agree that I shall be bound by and faithfully observe & abide by all the
rule & regulations relating to zero tolerance policy towards misselling. In case of breach of zero
tolerance policy towards misselling, I will be liable to pay a penalty of Rs. 50,000/- in addition
to loss of business of the Company.

17. ‘Adherence of Policies/Guidelines/Code of Conduct’

I hereby undertake & agree that I shall be bound by and faithfully observe & abide by all the
policies/guidelines/code of conduct rule & regulations issued & framed by the Company from
time to time.

18. Cancellation of Business of the Company

I hereby undertake, declare & agree that I shall not, either personally or through any person
including relative, company or through a partnership or as a proprietor, shareholder, joint
venture partner, collaborator, consultant, advisor, principal contractor or sub-contractor,
director, trustee, committee member, induce or attempt to induce any customer/client of the
Company to cease to be a customer/client of the Company, cancel

Signature ________•__________

9/11
Joining Report - Netambit
 any business of the Company including business which was sourced by me for the Company
while I was in the employment of the Company or otherwise and interfere with the relationship
between such a customer/client and the Company after my leaving the services of the
Company.

I fully understand that my inducement or attempt to induce any customer/client of the

Company to cease to be a customer/client of the Company, cancellation of any business of
Company or otherwise and interfere with the relationship between such a customer/client and
the Company in terms of above clause is an offence and that I shall never do the same. The
company will have all rights to take appropriate legal actions (civil and/or criminal) against me
for such act done by me and I will fully compensate the Company towards loss of business,
loss of reputation & goodwill and legal cost.

19. ‘Indemnification’

I hereby indemnify and hold the Company, its directors, officers, employees, representatives,
affiliates, associates, permitted assigns harmless of any and all such direct and indirect losses,
damages, costs, consequences, penalties as decided by the Company or legal action (civil as
well as criminal) that may be initiated against me or faced due to my non-compliance/non-
adherence/breach/violation of any of the terms & conditions contained in this Employee
Declaration.

I further declare that I will be fully & absolutely responsible for all such direct and indirect
losses, damages, costs, consequences, penalties as decided by the Company or legal action
(civil as well as criminal) and shall fully compensate for the same even after the termination of
my services from the Company.

I further declare that in addition to the above, the Company shall right in its absolute discretion
to take disciplinary action against me including but not limited to termination of my
employment, claiming compensation, forfeit of salary & full & final settlement dues etc.

20. ‘Law & Jurisdiction’

I agree that the provisions of this Employee Declaration shall be governed by and construed in
accordance with Indian Laws. The courts at Delhi /Uttar Pradesh will have exclusive/sole jurisdiction
to try and adjudicate upon all matters arising under this Employee Declaration.

21. Dual Employment

As per our company’ policy & code of conduct, we do not allow any direct or indirect association with
any entity or establishment (commercial or Non-commercial nature) in whatsoever capacity.

22. Relative Declaration

The Company does not promote and/or hire relatives in the Company or with any of our client where
you are being deputed. Members of a Personnel’s immediate family (defined as parents, children,
spouse, siblings, grandparents and those same relationships engendered by in-laws, adoptions and
step-families) and members of a Personnel’s household shall not be considered

Signature __________•_____________

10/11
Joining Report - Netambit
for employment as a regular practice. However, such cases can be considered on case to case basis
subject to certain conditions as imposed by the Company. In case, the facts are found to be
concealed, your employment shall be liable for termination and/or such other actions as deemed fit in
the Company’s sole discretion.

23. Sexual Harassment Prevention Committee & Training

We have a formal committee for prevention of sexual harassment at workplace guided by our internal
policy and governed by The Sexual Harassment of Women at Workplace (Prevention, Prohibition
and Redressal) Act, 2013 (hereinafter “Act”). We provide training at regular intervals as per the
provisions of the Act. You are hereby advised to kindly make a note of the contact details of the
committee members and report immediately to hrhelpdesk@netambit.in, in case you have any
complaint of Sexual Harassment as defined in the Act.

I hereby declare that I have read and completely understood all the terms & conditions of this
Employee Declaration and have signed the same. I further declare that I shall ensure full
compliance to the same during my employment with the Company and thereafter.

________•___________
Signature of employee

Name: ______

Date: ______

Place: _______

11/11
Joining Report - Netambit
 Bank Account Updation Form

Name (As per bank record):

Employee Code:

DOJ:

Bank Name:

Account Number:

IFSC Code:

Contact Number:

Manager Name:

Note:

 Please ensure that your bank account is activated before giving for updation
 Attach a recent ATM slip (that carries the Account number) with this form

I hereby confirm that my salary should be transferred in the above mentioned account.
I shall not held responsible to company or any other employee of the company for wrong transfer.

Signature: •

Date:

12/11
Joining Report - Netambit
 Employee code _______________
(Mandatory)
FORM 2 (Revised)

(For Unexempted /Exempted Establishments)

NOMINATION AND DECLARATION FORM
(Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme)
(Paragraphs 33 & 61 (1) of the Employees’ Provident Funds Scheme, 1952 and paragraph 18 of the Employees’ Pension Scheme, 1995)

1 Name (in Block Letters) :

2 Father’s/Husband’s Name :
3 Date of birth :
4 Sex :
5 Marital Status :
6 Account No. (PF/EPS Number) :
7 Address (Residential) : Permanent
Temporary

PART A (EPF) #
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate, the person(s) mentioned
below to receive the amount standing to my credit in the Employees’ Provident Fund, in the event of my death:

Name and Address of the nominee/ nominees Nominee’s Date of Total amount If the nominee is a
relationship Birth or share of minor, name and
with the accumulations relationship and
member in Provident address of the
Fund to be guardian who may
paid to each receive the amount
nominee (%) during the minority of
nominee
(1) (2) (3) (4) (5)

100%

100%

1 * Certified that I have no family as defined in para 2(g) of the Employees’ Provident Funds Scheme,
1952, and should I acquire a family hereafter, the above nomination should be deemed as cancelled.
2 * Certified that my father/mother is/are dependent upon me.
3. * Strike out whichever is not applicable.

----------------------•----------------------------
Signature or thumb impression of the subscriber

Note: - A Fresh nomination shall be made by the member on his marriage and any nomination made before
such marriage shall be deemed to be invalid

13/11
Joining Report - Netambit
 Page No. – 1
Part B (EPS) (Para 18) $
I hereby furnish below particulars of the members of my family who would be eligible to receive
widow/children pension in the event of my death.

Sl.No. Name and address of the family members Date of Birth Relationship with
the member

(1) (2) (3) (4)

1
2
3
4
** Certified that I have no family, as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and should
I acquire a family hereafter I shall furnish particulars thereon in the above form.

I hereby nominate the following persons for receiving the monthly widow pension (admissible under para 16 2(a)
(i) and (ii) of Employees’ Pension Scheme, 1995 in the event of my death without leaving any eligible family
member for receiving Pension. $$
Name and Address of the Nominee Date of Birth Relationship with the member

(1) (2) (3)

Dated the :______________ …………………•……………………

Signature or thumb impression
of the subscriber
**Strike out whichever is not applicable.

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by
Shri/Smt./Kumari________________________________________________________employed in my
establishment after he/she has read the entries/the entries have been read over to him/her by me and got
confirmed by him/her.

Place: ___________________

Dated the __________________

………………………………………………………….
Signature of the Employer or other authorised
Officer of the establishment
Designation……………………………………….
Name and address of the Factory/Establishment
or rubber stamp thereof

14/11
Joining Report - Netambit
Form 11 (Revised) Employee Code__________

THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (Paragraph 34)

AND
THE EMPLOYEES’ PENSION SCHEME, 1995 (Paragraph 24)
Declaration by a person taking up employment in an establishment in which the Employees’ Provident Funds &
Employees’ Pension Scheme enforce

I (Name of Employee) Son/ wife/ daughter of*Sh.

do hereby solemnly declare that :-

(a) I was employed in M/s (Name and Full Address of the immediate previous employer)
and left service on (Date of leaving with immediate previous employer) prior to that, I was employed in
from to
(Name and Full Address of the second last employer, if any)
(Date of joining & leaving with second last employer, if any)

(b) I was member of

(Name of PF Trust / Address of PF Office of immediate previous employer )
Provident Fund and also/but not* of the Pension Fund from to

(Date of joining & leaving with immediate previous employer).

and my account number (s) was/were
(PF No. with Establishment Code of immediate previous employer)

(c) I have / have not* withdrawn the amount of my Provident Fund/Pension Fund.

(d) I have / have not*drawn any superannuation benefits in respect of my past service from any employer.

(e) I have / have never* been a member of any Provident Fund and/or Pension Fund.

(f) I am drawing / not drawing* Pension under EPS 95.

(g) I am a holder / not holder* of scheme Certificate.

(h) Scheme certificate surrendered / not surrendered*.

*Strike out whichever is not applicable.

Date (Date of joining of employee)
•
Signature or left hand thumb
impression of the employee

(Designation with Co.)

Shri/Smt. (Name of Employee) is appointed as
in M/s NetAmbit ValueFirst Services Pvt Ltd. (Date of appointment)
with effect from
(Name of the present employer )

P.F. Account Number (PF No. with Estt. Code of present employer)

Date
(Date of joining of employee)
Signature of the Employer/Manager or Other
Authorised Officer with Office Seal

15/11
Joining Report - Netambit
 Payment of Gratuity (Central) Rules
FORM 'F'
See sub-rule (1) of Rule 6

Nomination

To,
(Give here name or description of the establishment with full address)
M/s NetAmbit ValueFirst Services Private Limited,
A-83, Ground Floor, Sector –2, Noida, Uttar Pradesh - 201301

I, Shri/Shrimati/Kumari
(Name in full here)
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to
receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my
death before that amount has become payable, or having become payable has not been paid and direct
that the said amount of gratuity shall be paid in proportion indicated against the name(s) of the
nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause
(h) of Section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said Act.

4 (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the to the
controlling authority in terms of the proviso to clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Nominee(s)

Name in full with full Relationship with Age of Proportion by which

address of nominee(s) the employee nominee the gratuity will be
shared

(1) (2) (3) (4)

1. 100%
2.
3.
So
on.

Signature ______•________

16/11
Joining Report - Netambit
 Statement
1. Name of employee in full
2. Sex
3. Religion
4. Whether unmarried/married/widow/widower
5. Department/Branch/Section where employed
6. Post held with Ticket No. or Serial No., if any
7. Date of appointment
8. Permanent address:
Village Thana Sub-division
Post Office District State

Place: ______________•___________
Signature/Thumb-impression of the
Employee
Date:

Declaration by Witnesses

Nomination signed/thumb-impressed before me

Name in full and full address of witnesses. Signature of Witnesses.
1. 1.

2. 2.

Place:
Date:

Certificate by the Employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any Signature of the employer/Officer authorised
Designation

Date: Name and address of the establishment or

rubber stamp thereof.

17/11
Joining Report - Netambit
 Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.
_________•________
Date: Signature of the Employee

Note.—Strike out the words/paragraphs not applicable.

18/11
Joining Report - Netambit
 FORM – 1

DECLARATION FORM (Regulation – 11& 12)

To be filled by the employee after reading instructions overleaf. Two Postcard size photographs are to be attached with this
form.
A) Insured Persons Particulars B) EMPLOYER’S PARTICULARS
1. Insurance No. 9. Employer‟s Code No:
2. Name 10. Date of Appointment Day Month Year
3. Father/Husband‟s Name
4. Date of Birth 11. Name & Address of the employer:
5 Sex : Male/Female : M/s NetAmbit ValueFirst Services Pvt Ltd,
A-83, Ground Floor, Sector – 2, Noida,
Uttar Pradesh - 201301
6 Marital Status : M/U :

7. Present Address 12. In case of any previous employment please fill the det. As under

a. Previous Ins. No.:

8. Permanent Address
b. Empr‟s Code No:

Branch Office: c. Name & Address of the Previous Employer

_____________________ Dispensary
____________________________
_______
(C) Details of Nominee u/s 71 of ESI Act
1948/Ruls 56(2) of ESI (Central) Rules 1950 for payment of each benefit in the event of death.
Name Relationship Address

_______________________ _____________•___________
Signature of the Employer Signature or the T.I./I.P of Employee

Family Particulars of Insured Person

Sl.No. Name Date of Birth/Age Relationship Whether residing If
No, State
With the employee with him/her
Place of
Yes No
Residing
1 YES
2 YES
3 YES
4
5
6
---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x----x---x---x---x---x---x---

19/11
Joining Report - Netambit
 Name
Insurance No.
Date of Appointment
Branch Office
Dispensary SPACE FOR PHOTOGRAPGH

Employer‟s Code No.

Employer‟s Name and M/s NetAmbit ValueFirst Services Pvt
Address Ltd,
A-83, Ground Floor, Sector – 2, Noida,
Uttar Pradesh - 201301

__________________•______________ _________________________
Validity Dated________ Signature of Employee Signature of Branch Manager with Seal

I hereby declare that the particulars given by me are correct to the best of my knowledge and belief. I undertake to intimate
the Corporation any changes in the membership of my family within 15 days of such change.
FOR BRANCH OFFICE USE ONLY

INSTRUCTIONS
1. Submission of Form–1 is governed by regulations 11& 12 of ESI (General) Regulations, 1950

2. „Family‟ means all or any of the following relatives of an insures person namely.
(i) a spouse (ii) a minor legitimate or adopted child dependant upon the I.P. (iii) a child who is wholly
dependent on the earnings of the I.P. 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 of mental
abnormality of injury and wholly dependant on the earnings of the I.P. so long as the infirmity
continues, (v) dependent parents (Please see section 2 clause 11 of the ESI Act 1948 for details)

3. Identity Card is Non-transferable.

4. Loss of identity Card is reported to the Employer/Branch Manager immediately.

5. Submission of false information attracts penal action under Section 84 of the ESI Act 1948

6. This form duly filled in must reach the concerned Branch Office within 10 days of appointment of an
Employee. Delay attracts penal action under Section 85 of the Act, against employer.

7. As in insured person you and your dependent family members are entitled to full medical card. The other
benefits in cash include (1) sickness benefit (2) Temporary Disablement benefit (30 Permanent disablement
Benefit (4) Dependents benefit and (5) Maternity benefit (In case of women employees) subject to fulfilments
of contributory conditions
8. For more details please visit website of ESIC at www.esic.org in or contact Regional office or Branch Office.

1. Date of allotment of Insurance No.______________________________________________

2. Date of issue of TIC:_________________________________________________________
3. Name/No: of Dispensary : ____________________________________________________
4. Whether reciprocal Medical arrangements involved?
If yes please indicate______________________________________
Signature of the Branch Manager
x--x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---x---

20/11
Joining Report - Netambit
 Family Particulars of Insured Person

Sl.No. Name Date of Birth/Age Relationship Whether residing If

No, State
With the employee with him/her
Place of
Yes No
Residing
1 Yes
2 Yes
3
4
5
6

Signature________•___________

21/11
Joining Report - Netambit
 NOMINATION OF BENEFICIARY FOR THE GROUP INSURANCE COVER UNDER THE GROUP POLICY
% share of all the benefits
Name Relationship nominated
1. 100%
2.
3.
4.
5.

Note: - If Beneficiary is a minor, please mention name a person ("Appointee") to receive policy proceeds in the
event of death of life insured, while the Beneficiary is still a minor. Please provide the below the following
information for Appointee".

Relationship to the
Name of Appointee: Beneficiary

Address:

Appointee's Signature

Name of Member (Mention Complete Name)

Signature of the Member •

Date: Place:

Emp Code

22/11
Joining Report - Netambit