Free form template · Word

Employee Assistance Program Form

An employee assistance program (EAP) form lets employees or their family request confidential support from the company's EAP provider, covering counselling, legal and financial guidance, and family or caregiving help. It explains confidentiality up front and collects only what the provider needs to make contact.

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[Company Logo][Company Name]

EMPLOYEE ASSISTANCE PROGRAMME (EAP) REQUEST FORM

Company:: [Company Name]
EAP Provider:: [Provider Name]
24x7 Helpline:: [Phone Number]
Date:: [Date]

Confidentiality: Your request goes to [Provider Name]. The company receives only anonymous, aggregated usage data. Information is shared only with your consent or where there is a serious risk to safety. If you are in immediate danger, call [Emergency Number] or go to the nearest hospital.

Who Needs Support

Name of Person Seeking Support
Relationship to Employee: Self / Spouse / Child / Parent
Employee ID (for eligibility check only)
City

Type of Support

Emotional wellbeing and counselling
Work stress or relationship at work
Family or relationship concerns
Legal information and guidance
Financial and debt guidance
Childcare or eldercare information
Grief or critical incident support

Referral

Self-referral / Manager-suggested
If manager-suggested: I agree to contact the EAP voluntarily: Yes / No

How Should We Contact You

Phone / Email / WhatsApp / Video
Contact Number or Email
Preferred Language
Best Time to Contact
Safe to leave a message: Yes / No

Consent

I request EAP support and consent to [Provider Name] contacting me using the details above. I understand the service is confidential, free for up to [Number] sessions per issue, and voluntary.

Requester
[Name]
Date: [Date]

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What this template includes

Confidentiality statement explaining what HR does and does not see
Type of support needed, beyond counselling
Self or manager referral with consent
Preferred contact method, language and time
Who will use the service: employee or family member
Crisis note pointing to immediate help

When to use it

When the company launches an EAP and wants employees to register
When an employee prefers a written request rather than calling the helpline
When a manager refers an employee to the EAP with their consent
After a critical incident when group support sessions are arranged

How to customise this template

1Insert your EAP provider name, helpline and app details
2List the services your EAP contract covers and the number of free sessions
3Decide whether the form goes to HR or directly to the provider
4Add language options relevant to your workforce

HR tips

Route forms directly to the provider where possible to protect confidentiality
Never record EAP use in performance or personnel files
Train managers to suggest the EAP without probing
Publicise the helpline regularly, not just at launch

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Frequently asked questions

What is an employee assistance program?+

An EAP is an employer-funded, confidential service offering counselling and practical support for personal or work issues, often extended to family members.

Will my manager know I used the EAP?+

Normally no. EAP providers share only anonymised usage numbers with the employer, unless there is a safety risk or you give consent.

Is a manager referral to EAP a disciplinary step?+

No. A referral is a supportive suggestion and participation remains voluntary.

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[Company Logo][Company Name]

EMPLOYEE WELLNESS PROGRAM: NEEDS AND INTEREST FORM

Company:: [Company Name]
Survey Period:: [DD/MM/YYYY] to [DD/MM/YYYY]
Coordinator:: [HR Name]

We are planning our wellness calendar for [Year]. Your answers will help us choose activities that suit you. Questions about health are optional and responses will be reported only in aggregate.

About You (optional)

Name (optional)
Department
Work Location
Work Pattern: General Shift / Rotational Shift / Remote / Hybrid
Age Group: Under 25 / 25-34 / 35-44 / 45-54 / 55+

Rate Your Interest (1 = low, 5 = high)

Programme	Interest (1-5)	Preferred Format
Yoga and stretching	[1-5]	[On-site / Online]
Gym or fitness challenge	[1-5]	[On-site / App]
Nutrition and diet talks	[1-5]	[On-site / Online]
Stress management and mental health	[1-5]	[On-site / Online]
Sleep and lifestyle workshops	[1-5]	[Online]
Financial wellness (tax, savings)	[1-5]	[Online]
Preventive health check-up	[1-5]	[On-site / Lab]

Form · Word

Employee Wellness Program Form

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[Company Logo][Company Name]
EMPLOYEE WELFARE ASSISTANCE REQUEST
Company:
[Company Name]
Request No.:
[Reference Number]
Date:
[Date]
Handling:
Confidential
Applicant
Employee Name (or family member applying on behalf)
Employee ID
Department
Years of Service
Mobile Number
Nature of Hardship
- Medical emergency (self or dependant)
- Death in the family
- Natural calamity / fire / accident to property
- Other serious hardship: [Details]
Details of Need
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[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
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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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Employee Name (or family member applying on behalf)
Employee ID
Department
Years of Service
Mobile Number

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]

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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[Company Logo][Company Name]
EMPLOYEE WELFARE FUND MEMBERSHIP FORM
Fund:
[Company Name] Staff Welfare Fund
Managed by:
Welfare Committee, [Work Location]
Form No.:
[Reference Number]
Date:
[Date]
Member Details
Employee Name
Employee ID
Department
Designation
Date of Joining
Mobile Number
Contribution
Contribution Option Employee (₹/month) Company Matching (₹/month) Select
Basic [Amount] [Amount] [ ]
Standard [Amount] [Amount] [ ]
Enhanced [Amount] [Amount] [ ]
Purposes the Fund May Support
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Employee Welfare Fund Form
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Member Name (as currently on e-card)
Relationship
E-card / Member ID

Contribution Option	Employee (₹/month)	Company Matching (₹/month)	Select
Basic	[Amount]	[Amount]	[ ]
Standard	[Amount]	[Amount]	[ ]
Enhanced	[Amount]	[Amount]	[ ]

[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

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Benefits Selection Form

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Employee Assistance Program Form

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Who Needs Support

Type of Support

Referral

How Should We Contact You

Consent

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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