EMPLOYEES' STATE INSURANCE CORPORATION

e-Pehchan Card

Insured Person : Rafik Molla THIS CARD IS VALID up to 07/02/2016 *(If Aadhaar number is not entered)
Insurance No. : 4115271081 For extending the validity, please get the Aadhaar number of self and family
Date of Registration : 09/01/2016 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: Rafik Molla Type of Disability : None

Name of Father / Husband: LIYAKAT MOLLA Date of Birth : 01/01/1987

Marital Status : Married Gender : Male

VILL-BALARAMPOTA (MOLLAPARA),P.O- VILL-BALARAMPOTA

Present Address : Permanent Address :
PANCHLA,P.S-ULUBERIA,Dist:Howrah,West (MOLLAPARA),P.O-
Bengal,711322 PANCHLA,P.S-ULUBERIA,Dist:Howrah,W
est Bengal,711322

Aadhaar : NA Aadhaar Status : NA

Dispensary / IMP : Uluberia, WB (ESIS Disp.)

Current Employer Details First Employer Details

Employer's Code No. : 41000625170000999 Employer's Code No. : None

Sub Unit's Code No. : None Sub Unit's Code No. : None
Date of Appointment : 01/04/2016 First Insurance No. : None

Name of Employer : SAMIM MOLLA Name of Employer : None

BALARAMPOTA
Address of Employer : Address of Employer : None
PANCHLA,ULUBERIA,Dist:HowrahWest
Bengal711322

Family Details:
Relationship Whether
Name Date of Birth State District Aadhaar Aadhaar Status
with the Residing with
Employee Insured Person
LIYAKAT MOLLA Dependant father
07/01/1975
West Bengal Howrah
NA NA
Yes

SALMA KHATUN Spouse

05/01/1988
West Bengal Howrah
NA NA
Yes

RIJIYA BIBI Dependant mother

01/01/1972
West Bengal Howrah
NA NA
Yes

Nominee Details:
Name of Nominee Relationship with IP Percentage Address of Nominee Aadhaar Aadhaar Status
SALMA KHATUN Spouse VILL-BALARAMPOTA (MOLLA
100 NA NA
PARA),P.O-
PANCHLA,P.S-ULUBERIA,West
BengalDist:Howrah711322
Documents Uploaded:
none

Signature / LTI of Registered Employee / IP :

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

Mobile Number : 9804777993

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