[Company Logo][Company Name]
EMPLOYEE FAMILY DETAILS FORM
- Employee Name:
- [Employee Name]
- Employee ID:
- [Employee ID]
- Date of Joining:
- [Date of Joining]
- Date:
- [Date]
Please list only those family members who should be covered under a benefit. Leave the form blank if you do not wish to enrol anyone.
| Sl. | Name of Family Member | Relationship | Date of Birth | Gender | Residing with Employee (Y/N) | Dependent (Y/N) | Purpose |
|---|---|---|---|---|---|---|---|
| 1 | [Name] | [Spouse] | [DD/MM/YYYY] | [Gender] | [Y/N] | [Y/N] | [Insurance / ESIC / Nomination] |
| 2 | [Name] | [Son / Daughter] | [DD/MM/YYYY] | [Gender] | [Y/N] | [Y/N] | [Purpose] |
| 3 | [Name] | [Relationship] | [DD/MM/YYYY] | [Gender] | [Y/N] | [Y/N] | [Purpose] |
| 4 | [Name] | [Relationship] | [DD/MM/YYYY] | [Gender] | [Y/N] | [Y/N] | [Purpose] |
Benefits Selected
- Group health insurance
- ESIC family coverage (if wages within the ESI limit)
- Use as reference for nominations
Privacy notice: [Company Name] collects the details on this page only for enrolling your family members in the benefits selected and supporting nominations. Access is limited to authorised HR staff, and the record will be kept for the period the benefit is active and the retention period thereafter, after which it will be securely deleted or destroyed. You may ask HR to see or correct your data, consistent with the Digital Personal Data Protection Act, 2023.