LIST
OF EMPLOYEES DRAWING WAGES EXCEEDING RS. 6500/- BUT NOT EXCEEDING RS. 7500/- PER
MONTH COVERABLE UNDER THE ESI ACT, 1948, W.E.F. 01.04.2004.
The
Branch Manager
ESI Corporation
--------------------
I hereby declare that the under-mentioned
employees working in the aforesaid factory/ establishment, including employees
of the contractor(s), have been brought under the ambit of the ESI Act, 1948
(as amended) consequent upon enhancement of wage ceiling for coverage from Rs.
6500/- to Rs. 7500/- per month w.e.f. 1.4.2004.
| Sl.
No. |
Name |
Ins.
No. if earlier covered under the Act |
Branch
Office to which attached (write N.A in r/o newly covered employees |
Total
amount of monthly salary/ wages excluding OTA paid/ payable from 1.4.2004 |
Name
of ESI Dispensary/ Hospital |
Remarks |
The declaration forms of the newly coverable and re-entered employees are enclosed for allotment of Insurance number / revalidation of old identity cards/ issuance of duplicate identity cards.
Certified
that the above particulars are correct in every respect and no employee
including part-time / daily rated /
contractors’ employees have been left out.
| Date
: Place
: |
Signature of principal employer
: Name: Designation : M/s
_____________________________ |