EMPLOYEES' STATE INSURANCE CORPORATION

e-Pehchan Card

Insured Person : Tintu Varghese Manjali THIS CARD IS VALID up to 08/05/2014 *(If Aadhaar number is not entered)
Insurance No. : 4810276935 For extending the validity, please get the Aadhaar number of self and family
Date of Registration : 09/04/2014 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: Tintu Varghese Manjali Type of Disability : None

Name of Father / Husband: VARGHESE Date of Birth : 09/10/1985

Marital Status : Married Gender : Male

MANJALI MANJALI
Present Address : Permanent Address :
HOUSE,MAPRANAM,MADAYIKONAM HOUSE,MAPRANAM,MADAYIKONAM
PO,Dist:Thrissur,Kerala PO,Dist:Thrissur,Kerala

Aadhaar : 793980972796 Aadhaar Status : Verified

Dispensary / IMP : Irinjalakkuda, KL (ESIS Disp.)

Current Employer Details First Employer Details

Employer's Code No. : 78000311430001002 Employer's Code No. : None

Sub Unit's Code No. : None Sub Unit's Code No. : None
Date of Appointment : 01/03/2014 First Insurance No. : None

Name of Employer : MANJALY THRISSUR FASHION JEWELLERY Name of Employer : None

Main Road,ATTINGAL - 695
Address of Employer : Address of Employer : None
102,THIRUVANANTHAPURAM,Dist:Thiruva
nanthapuramKerala695102

Family Details:
Relationship Whether
Name Date of Birth State District Aadhaar Aadhaar Status
with the Residing with
Employee Insured Person
MARIYAMMA Dependant mother
04/05/1956
Kerala Thrissur
889182352214 Unverified
Yes
VARGHESE

MARIYA TINTU Spouse

31/10/1996
Kerala Thrissur
333217823840 Unverified
Yes

Nominee Details:
Name of Nominee Relationship with IP Percentage Address of Nominee Aadhaar Aadhaar Status
MARIYA TINTU Spouse AS
100 333217823840 Unverified
ABOVE,KeralaDist:Thrissur6803
21
Documents Uploaded:
none

Signature / LTI of Registered Employee / IP :

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

Mobile Number : 9895185158

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