An employee declaration form is a set of formal statements signed by an employee confirming that their information is true, that they have no conflicting employment, and disclosing any conflicts of interest or relatives in the company. It is signed at joining and refreshed annually in many companies.
I declare that all information and documents I have given to [Company Name] are true and complete, and I have not withheld any material fact.
2. Other Employment
I am not employed with, or providing paid services to, any other organisation
I have other engagements, disclosed below, for HR's approval
Details of other engagement (if any)
3. Conflict of Interest
Business interests, directorships or investments in competitors, customers or vendors (if any)
Relatives employed in the company or with its vendors (name, relationship, department)
4. Policy Acknowledgement
Code of Conduct
Prevention of Sexual Harassment (POSH) Policy
IT Acceptable-Use and Confidentiality Policy
Anti-bribery Policy
The disclosures in this form are confidential and are used only to manage conflicts of interest and compliance. They are reviewed by HR and, where needed, the compliance officer, and kept for the duration of employment, in accordance with the Digital Personal Data Protection Act, 2023.
Declaration
I understand that a false declaration may lead to action under company policy, and I will inform HR promptly of any change to the above.
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.
I authorise [Company Name] to recover ₹[Amount] per [month / year] from my salary towards the premium for the dependants added above, as per the company insurance policy.