Sample EPF Declaration form (For Reference purpose only)
Employee Full Name (as per Aadhar) Father’s/Husband’s Name (as applicable)
Employee DOB
(as per Aadhar) Employee Previous PF account number
As Applicable As Applicable
As Applicable
Fill your EPF
nominations
with
appropriate
information as
per
instructions
from the
Guide.
Employee Signature
Fill your EPS
nominations
(If
APPLICABL
E ONLY) with
appropriate
information as
per
instructions
from the
Guide.
Fill your
Widow
pension
nominations
(IF
APPLICABLE
ONLY)
Employee Signature
To be filled by Employer
valid email for communication. Valid Contact number linked to your
Employee Full Name (as per Aadhar)
Aadhar and UAN (if existing)
As Applicable
Employee Date of Birth (as per Aadhar)
As Applicable
Valid email for communication. Valid Contact number
linked to your Aadhar and UAN (if existing)
Circle/Write YES if you are PF
member earlier. NO if not applicable.
*MANDATORY to FILL
Fill your UAN and Circle/Write YES if you are EPS
PF account numbers member earlier. TO know your EPS
status, please check in you PF
passbook. *MANDATORY to
As Applicable
FILL (Refer Guidelines if needed)
Circle/Write YES if you are an
international worker. NO Otherwise.
Refer to Guidelines if needed.
As Applicable
*MANDATORY to FILL
Fill your BANK details linked to your PF account.
IF you don’t have UAN earlier, a new account will
be created, and you are required to activate your
UAN and complete KYC in EPFO portal.)
Employee Signature
As Applicable
To be filled by Employer
s
“Experian Services India [Link]” (Name of Establishment)
Employee Name
Tick appropriates
whichever is
applicable and fill
your Gratuity
nomination in
below Table.
Fill Nomination
As per your
preference.
Refer to
Guidelines if
Refer to
Guidelines if
needed.
needed.
Declaration by employee for Gratuity
eligibility. Fill details as needed.
Employee Signature
As Applicable
Names & Signatures of any two
witnesses (not necessarily from
family)
As Applicable
To be filled by Employer
Employee Signature
NOMINATION FORM
For Group Term Life s Group Personal Accident Policy
Insurance nomination form. Fill your nominee details for both
group term life and personal accident policy provided by
Note:
organization. Refer Guidelines if needed.
1. The form must be filled in and duly signed by the employee.
2. The company expresses no opinion as to the validity of the nomination declared by the employee.
Employee Name
Employee Designation
Employee Date of Birth
Employee Date of Joining
Nominee details for Group Term Life
I, as an employee of Experian Services India Private Limited (ESIPL) nominate following person(s), to
whom the Group Term Life Insurance benefits shall be paid in event of my death.
Name of Date of Relationship with % of Communication address
Nominee Birth Employee share (Including phone number)
Nominee details for Group Personal Accident
I, as an employee of Experian Services India Private Limited (ESIPL) nominate following person(s), to
whom the Group Personal Accident Insurance benefits shall be paid in event of my death.
Name of Date of Relationship with % of Communication address
Nominee Birth Employee share (Including phone number)
Employee Signature
Signature/Thumb Impression of Employee
Employee Self declaration form.
*Fill details as applicable.
FORM - I
Nominated and Declaration Form
(See Rule 3)
1. Name of the person making
nomination 5. Marital Status
(In Block Letters)
2. Father's/ Husband's Name: 6. Address:
3. Date Of Birth Permanent:
4. Sex: Temporary:
I hereby nominated the person (s)/cancel the nomination made by me previously and nominate the
person(S) mentioned below to receive any amount due to me from the employer, in the event to my
Death.
Total Amount If the nominee is minor,
of share of name relationship and
Name of Nominee's
accumulations address of the guardian who
the Relationship Date Of
Address in credit to be may receive the amount
Nominee/ With Birth
paid to each during the minority of
Nominees Member
nominee nominee
(1) (2) (3) (4) (5) (6)
1. I certify that I have no family and should I acquire a family hereafter, the above nomination shall be
deemed as cancelled.
2. *Certify that my father/mother is/ are dependent upon me.
3.*Strikeout whichever is not applicable.
Employee Signature
Signature or the thumb impression of the
employed person.
CERTIFICATE BY THE EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by
Shri/Smt./Kum Employed in my establishment after he/she has
read the entry/entries has been read over to him/her by me and got confirmed by him/her.
To be filled by Employer
Signature of the employer or other authorized
officer of the establishment and Designation
Place:
Date:
Name and address of the Establishment and
Rubber Stamp thereof