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Form guide · Source checked 21 October 2026
ESIC Form 4: identity card and e-Pehchan context
The legacy Regulation17 identity card is prepared through ESIC; the sample explains its fields and the current e-Pehchan retrieval route without creating a valid card.
Identified 1950 Regulations form / saved transition and online procedure; checked 21 October 2026
Download and read the completed example
Completed fictional identity card and e-pehchan context for Illustration Office Services Pvt Ltd (fictional), 14 Example Park, New Delhi 110001. Synthetic identifiers cannot be used for filing or medical care.
Fictional, unsigned completed illustration. It demonstrates this form’s fields; it is not a filed return, medical opinion, official order or proof of an actual transaction.
When and how this form is used
Regulation17 describes ESIC preparing Form4 and delivery through the employer after the stated three-month service condition in that paper procedure. The employee cannot self-issue an authenticated ESIC identity card from this sample.
ESIC’s employer guide describes issuance of e-Pehchan on registration, retrieval through the IP portal/UMANG, photographs and countersignature by the employer or designated Branch Manager. Follow that current identified online route under Regulation110; do not tell a newly registered person to wait three months before seeking the e-Pehchan download.
The printed source page also contains separate Form4-A for a family card. It is not a second Form4 application. Family particulars and changes must match the actual ESIC record; do not fabricate a family photograph or medical entitlement.
The completed fields
Identified Form4 fields
| Prescribed field / section | Completed fictional entry |
|---|---|
| Insurance number | [synthetic IP DEMO-0001; not a valid insurance number] |
| Name / sex / parent or spouse | Ravi Kumar; male; son of Meera Kumar; spouse field N/A in this model |
| Year of birth / address | 1995; 5 Example Street, New Delhi110001 (fictional) |
| Dispensary / local office | Assigned ESIC dispensary / appropriate Branch Office, New Delhi; actual allotment not represented |
| Identification marks / photograph | Fictional mark: small old scar on left forearm; no real patient photograph supplied or reproduced; photograph field marked not executed |
| Prepared by / insured person signature | Hypothetical ESIC preparer, not a real official; Ravi Kumar signature/thumb impression not executed |
| Employment changes: both date/code pairs | 1 January2026 / [synthetic employer code DEMO-ESI; not valid]; second change N/A, no later change assumed |
Supporting records and reconciliation
Actual insurance allotment, correctly linked personal/family particulars, authentic photograph, employer/Branch countersignature and genuine e-Pehchan output. This unsigned field transcription is not identity evidence.
Official source and version
Download the official source pages containing this form. Adjacent prescribed forms can share a source page; use the heading and rule identified above.
These are the identified ESI (General) Regulations 1950 forms and the online procedures described by ESIC. Code on Social Security section164(2)(b) saves the earlier ESI rules/regulations for one year from commencement to the extent consistent. The 13 July 2026 instrument published in Gazette274902 is expressly a DRAFT inviting objections; it cannot by itself substitute these forms. The examples are source-checked on 21 October 2026 within the identified transition, not a claim that an old paper layout is the current portal screen.
Practical questions
Can I submit the sample as my own completed form?
No. Replace the fictional facts with accurate records, use the competent filing or record-keeping route described above and complete genuine signatures or certifications where required.
What makes the example specific to this form?
The legacy Regulation17 identity card is prepared through ESIC; the sample explains its fields and the current e-Pehchan retrieval route without creating a valid card.