Free form template · Word

Benefits Selection Form

A benefits selection form lets employees choose how to spread a fixed flexible-benefits amount within their CTC across components like meal, fuel, telephone, LTA and NPS. It is filled at joining and at the start of each financial year so payroll can structure tax-efficient pay.

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[Company Logo][Company Name]

FLEXIBLE BENEFITS SELECTION FORM

Company:: [Company Name]
Financial Year:: [FY 20XX-XX]
Submission Date:: [Date]
Payroll Cut-off:: [DD/MM/YYYY]

Part 1: Employee Information

Employee Name
Employee ID
Designation
Department
Annual CTC: ₹[CTC]
Annual Flexi Basket: ₹[Amount]
Tax Regime Opted: Old / New

Part 2: Allocation of Flexi Basket

Component	Company Limit per Month (₹)	My Monthly Allocation (₹)	Annual Allocation (₹)	Bills Required
Meal Card / Food Coupons	[Amount]	[Amount]	[Amount]	No (card based)
Fuel and Vehicle Maintenance	[Amount]	[Amount]	[Amount]	Yes
Telephone and Internet	[Amount]	[Amount]	[Amount]	Yes
Leave Travel Allowance	[Amount]	[Amount]	[Amount]	Yes, travel proof
Books and Periodicals	[Amount]	[Amount]	[Amount]	Yes
Employer NPS Contribution	[Amount]	[Amount]	[Amount]	No
Total (must equal flexi basket)	-	[Amount]	[Amount]	-

Part 3: Terms

The selection applies from [DD/MM/YYYY] until the end of the financial year unless HR opens a change window.
Reimbursable components will be paid only against original or valid digital bills submitted by the due date.
Any amount not claimed by the year-end cut-off will be paid as taxable special allowance.
Tax treatment depends on the regime chosen and prevailing tax law; the company does not give tax advice.
If no form is received, the full basket will be paid as taxable special allowance.

Declaration

I have read the terms above and request [Company Name] to structure my salary as per this allocation. I understand that claims must be genuine and supported by bills, and that false claims may lead to recovery and disciplinary action.

Employee
[Employee Name]
Date: [Date]

Payroll / HR
[HR Name]
Date: [Date]

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What this template includes

Total flexi basket amount printed from the offer or revision letter
Component-wise allocation table with company-set monthly limits
Balance column so the total equals the basket and nothing is left unallocated
Treatment of unclaimed amounts, for example paid as taxable special allowance
Tax regime chosen, since some components give no benefit under the new regime
Lock-in statement that choices apply for the financial year

When to use it

At the start of the financial year when employees restructure their flexi benefit plan
When a new joiner's CTC includes a flexible benefits basket
After a salary revision that changes the size of the flexi amount
When an employee switches between the old and new tax regime and wants to reallocate

How to customise this template

1Replace the component list with the components your payroll actually supports
2Enter the maximum monthly limit your policy allows per component
3State the bill submission frequency, for example quarterly, for reimbursable components
4Mention the payroll cut-off date by which the form must reach HR
5Add a mid-year change window if your policy allows one

HR tips

Remind employees that reimbursable components need valid bills; unclaimed amounts are taxed
Avoid quoting tax exemption limits on the form; refer employees to the current payroll FAQ instead
Do not allow the total allocation to exceed the basket, payroll will reject it
Share an example filled form so first-time employees understand the arithmetic

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Frequently asked questions

What is a benefits selection form?+

It is a declaration where you split your flexible benefits amount across allowed components. Payroll uses it to structure your monthly salary for the year.

Can I change my flexi benefit selection mid-year?+

That depends on company policy. Many employers allow changes only at the start of the financial year or after a salary revision.

What happens to unused flexi amounts?+

Usually any amount not supported by bills is paid out as taxable allowance at year end or in the March payroll, as stated in your policy.

All 50 employee benefits & insurance →

[Company Logo][Company Name]
EMPLOYEE BENEFITS ENROLLMENT FORM
Company:
[Company Name]
Form No.:
[Reference Number]
Date of Submission:
[Date]
Enrollment Deadline:
[DD/MM/YYYY]
Please complete all sections within the enrollment window and return this form to [HR Name], Human Resources. Benefits will be activated only after HR verification.
Section A: Employee Details
Employee Name (as per PAN)
Employee ID
Designation
Department
Date of Joining
Work Location
Date of Birth
Gender
Mobile Number
Personal Email
PAN
Aadhaar (last 4 digits only)
Section B: Statutory Benefits
UAN (if already allotted)
Previous PF Account / Member ID
ESI IP Number (if applicable, for gross wages up to ₹21,000/month)
Opting for higher PF contribution: Yes / No
Form · Word
Employee Benefits Enrollment Form
Download .docx

Employee Name (as per PAN)
Employee ID
Designation
Department
Date of Joining
Work Location
Date of Birth
Gender
Mobile Number
Personal Email
PAN
Aadhaar (last 4 digits only)

UAN (if already allotted)
Previous PF Account / Member ID
ESI IP Number (if applicable, for gross wages up to ₹21,000/month)
Opting for higher PF contribution: Yes / No

[Company Logo][Company Name]

GROUP INSURANCE NOMINATION FORM

Company:: [Company Name]
Policy:: Group Term Life / Group Personal Accident
Insurer:: [Insurer Name]
Policy No.:: [Policy Number]
Date:: [Date]

Employee Details

Employee Name
Employee ID
Designation
Department
Date of Birth
Date of Joining
Marital Status

Nominee Details

Nominee Name	Relationship	Date of Birth	Address and Mobile	Share (%)
[Nominee Name]	[Relationship]	[DD/MM/YYYY]	[Address, Mobile]	[%]
[Nominee Name]	[Relationship]	[DD/MM/YYYY]	[Address, Mobile]	[%]
[Nominee Name]	[Relationship]	[DD/MM/YYYY]	[Address, Mobile]	[%]
Total				100%

Appointee (only if a nominee is a minor)

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Group Insurance Nomination Form

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[Company Logo][Company Name]
MEDICLAIM DECLARATION
Company:
[Company Name]
Policy Year:
[DD/MM/YYYY] to [DD/MM/YYYY]
Date:
[Date]
A. Employee Particulars
Employee Name
Employee ID
Department
Designation
Date of Birth
Contact Number
B. Choice of Cover (tick one)
- I opt IN to the group mediclaim for myself and the dependants listed in Part C.
- I opt IN for myself only.
- I opt OUT of the group mediclaim. I am covered under policy no. [Policy Number] with [Insurer Name]. I understand I cannot claim under the company policy and may rejoin only at renewal, if permitted.
C. Dependants Declared for this Policy Year
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Mediclaim Declaration Form
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[Company Logo][Company Name]
HEALTH INSURANCE CLAIM SUBMISSION FORM (INTERNAL)
Company:
[Company Name]
Insurer / TPA:
[Insurer Name] / [TPA Name]
Policy No.:
[Policy Number]
Internal Claim Ref.:
[Reference Number]
Date of Submission:
[Date]
Important: This form helps HR process your claim. The insurer's or TPA's official claim form must also be completed, signed and attached where required.
1. Employee Details
Employee Name
Employee ID
Department
Mobile Number
Email ID
2. Patient Details
Patient Name
Relationship to Employee
Age
E-card / Member ID
TPA Claim Intimation No. (if any)
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Health Insurance Claim Form
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[Company Logo][Company Name]
INSURANCE CLAIM ASSISTANCE REQUEST
Company:
[Company Name]
Request No.:
[Reference Number]
Date:
[Date]
Priority:
Urgent (in hospital) / Normal
Employee and Policy
Employee Name
Employee ID
Department
Mobile Number
Policy Type: Group Health / Group Personal Accident / Group Term Life
Patient / Insured Member Name
TPA / Insurer Claim Number
Nature of Assistance Needed
- Cashless approval pending
- Reimbursement claim delayed
- Claim rejected, request review
- Claim partly settled / deductions unclear
- Document query from TPA
- Other: [Details]
Claim Summary
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Insurance Claim Assistance Form
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Patient Name
Relationship to Employee
Age
E-card / Member ID
TPA Claim Intimation No. (if any)

[Company Logo][Company Name]

EMPLOYEE INSURANCE DETAILS FORM

Company:: [Company Name]
Record Date:: [Date]
Last Updated:: [DD/MM/YYYY]

Employee Information

Employee Name
Employee ID
Designation
Department
Work Location
Date of Joining
Mobile Number

Coverage Summary

Cover	Insurer	Policy No.	Member / E-card ID	Sum Insured (₹)	Valid Till
Group Mediclaim	[Insurer Name]	[Policy Number]	[Member ID]	[Amount]	[DD/MM/YYYY]
Group Term Life	[Insurer Name]	[Policy Number]	[Member ID]	[Amount]	[DD/MM/YYYY]
Group Personal Accident	[Insurer Name]	[Policy Number]	[Member ID]	[Amount]	[DD/MM/YYYY]
Voluntary Top-up	[Insurer Name]	[Policy Number]	[Member ID]	[Amount]	[DD/MM/YYYY]

Statutory Coverage

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Employee Insurance Details Form

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[Company Logo][Company Name]
INSURANCE BENEFICIARY DESIGNATION / CHANGE FORM
Company:
[Company Name]
Form Ref.:
[Reference Number]
Date:
[Date]
Effective From:
[DD/MM/YYYY]
Employee Details
Employee Name
Employee ID
Department
Designation
Mobile Number
Policies Affected
- Group Term Life, Policy No. [Policy Number]
- Group Personal Accident, Policy No. [Policy Number]
- Voluntary Life Cover, Policy No. [Policy Number]
Type of Request
Form · Word
Insurance Beneficiary Form
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Form · Word
Employee Insurance Correction Form
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Member Name (as currently on e-card)
Relationship
E-card / Member ID

Benefits Selection Form

Preview of the form

Part 1: Employee Information

Part 2: Allocation of Flexi Basket

Part 3: Terms

Declaration

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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