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Dependent Insurance Enrollment

A dependent insurance enrollment form is used by an employee to enroll eligible family members, such as a spouse, children or parents, into the company group health policy. It focuses on eligibility, relationship proof and premium sharing for each dependant.

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[Company Logo][Company Name]

DEPENDENT INSURANCE ENROLLMENT FORM

Company:: [Company Name]
Policy:: Group Mediclaim, No. [Policy Number]
Enrollment Window:: [DD/MM/YYYY] to [DD/MM/YYYY]
Date:: [Date]

Employee Details

Employee Name
Employee ID
Department
Mobile Number
Current Coverage: Self only / Self + Family

Eligibility Summary (from policy)

Spouse: legally wedded spouse, one at a time.
Children: up to [Number] children, up to age [Age] years.
Parents / Parents-in-law: either set, subject to premium of ₹[Amount] per person per year.
Dependants may be added at joining, within [Number] days of a life event, or at renewal.

Dependants to be Enrolled

Name	Relationship	Date of Birth	Gender	Proof Attached	Premium (₹)
[Dependant Name]	[Relationship]	[DD/MM/YYYY]	[M/F]	[Document]	[Amount]
[Dependant Name]	[Relationship]	[DD/MM/YYYY]	[M/F]	[Document]	[Amount]
[Dependant Name]	[Relationship]	[DD/MM/YYYY]	[M/F]	[Document]	[Amount]

Proof Checklist

Marriage certificate or spouse ID showing relationship
Birth certificate of child
Parent ID proof with date of birth
Masked Aadhaar copies (last 4 digits visible)

Premium Consent and Declaration

I request enrollment of the dependants listed above. I authorise [Company Name] to deduct the employee share of premium of ₹[Amount] from my salary. I confirm that the persons listed are my dependants as defined in the policy and that the details and documents provided are genuine.

Employee
[Employee Name]
Date: [Date]

HR / Benefits
[HR Name]
Endorsement Requested: [Date]

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What this template includes

Eligibility rules summarised from the policy, such as child age limits
Dependant details table with proof type
Premium per dependant and who pays it
Relationship proof checklist
Confirmation that the dependant is not covered under another employer group policy, if your policy needs it
Effective date as per insurer endorsement

When to use it

When an employee could not enroll family at joining and the policy allows it at renewal
When parental cover is offered as a voluntary add-on
When a child crosses or nears the dependent age limit and status must be confirmed
When a spouse loses cover from their own employer

How to customise this template

1Insert your policy's dependant definition and age limits
2Enter the per-head premium for voluntary dependants
3List the proof documents your insurer accepts
4State the windows in which dependants can be added

HR tips

Accept masked ID copies; you rarely need full Aadhaar numbers
Explain that cover starts from the insurer's endorsement date, not the form date
Keep sibling or in-law eligibility only if your policy actually allows it
Deduct premium only after the employee signs the consent

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Frequently asked questions

Which dependants can be added to group health insurance?+

Usually spouse and children, and sometimes parents or parents-in-law. Your policy schedule defines who counts as a dependant and any age limits.

Do I have to pay extra for adding parents?+

Often yes. Many companies fund cover for spouse and children but recover parental premium from salary. The form shows the amount.

What proof is needed to add a dependant?+

Commonly a birth certificate for children, a marriage certificate or joint ID for spouse, and ID proof showing relationship for parents.

All 50 employee benefits & insurance →

[Company Logo][Company Name]
GROUP MEDICAL INSURANCE (GMC) ENROLLMENT FORM
Policyholder:
[Company Name]
Insurer:
[Insurer Name]
TPA:
[TPA Name]
Policy No.:
[Policy Number]
Policy Period:
[DD/MM/YYYY] to [DD/MM/YYYY]
1. Primary Member (Employee)
Employee Name (as per ID proof)
Employee ID
Date of Birth
Gender
Date of Joining
Work Location
Mobile Number
Email ID
2. Coverage Selection
Sum Insured Tier: ₹[Amount] / ₹[Amount] / ₹[Amount]
Basis: Family Floater / Individual
Voluntary Top-up: Yes / No, Sum Insured ₹[Amount]
Parental Cover: Parents / Parents-in-law / None
3. Family Members to be Covered
Form · Word
Group Medical Insurance Enrollment
Download .docx
[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 ID proof)
Employee ID
Date of Birth
Gender
Date of Joining
Work Location
Mobile Number
Email ID

Sum Insured Tier: ₹[Amount] / ₹[Amount] / ₹[Amount]
Basis: Family Floater / Individual
Voluntary Top-up: Yes / No, Sum Insured ₹[Amount]
Parental Cover: Parents / Parents-in-law / None

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)

Form · Word

Group Insurance Nomination Form

Download .docx

[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)
Form · Word
Health Insurance Claim Form
Download .docx
[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
Form · Word
Insurance Claim Assistance Form
Download .docx

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

Form · Word

Employee Insurance Details Form

Download .docx

[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
Download .docx

[Company Logo][Company Name]

REQUEST FOR ADDITION OF MEMBERS

Ref. No.:: [Reference Number]
Date:: [Date]

To,
[Insurer / Broker Name]
[Address]

Subject: Addition of members under Policy No. [Policy Number] – [Company Name]

Dear Sir/Madam,

Please add the following members to our group policy(ies) with effect from the dates mentioned below. Kindly adjust the applicable premium against our CD Account No. [Account Number] and share the endorsement copy and e-cards at the earliest.

Emp ID	Member Name	Relationship	Date of Birth	Gender	Effective Date	Policies (GMC/GTL/GPA)	Sum Insured (₹)
[Employee ID]	[Employee Name]	Self	[DD/MM/YYYY]	[M/F]	[Date of Joining]	[GMC, GTL, GPA]	[Amount]
[Employee ID]	[Member Name]	Spouse	[DD/MM/YYYY]	[M/F]	[DD/MM/YYYY]	[GMC]	[Amount]
[Employee ID]	[Member Name]	Child	[DD/MM/YYYY]	[M/F]	[DD/MM/YYYY]	[GMC]	[Amount]
[Employee ID]	[Employee Name]	Self	[DD/MM/YYYY]	[M/F]	[Date of Joining]	[GMC, GTL]	[Amount]

Summary

Form · Word

Employee Insurance Addition Request

Download .docx

Dependent Insurance Enrollment

Preview of the form

Employee Details

Eligibility Summary (from policy)

Dependants to be Enrolled

Proof Checklist

Premium Consent and 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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