An employee information verification form records how HR checked the details an employee provided, such as identity, education, past employment and address. It shows the source used, the result and any discrepancy, and requires the employee's consent before third-party checks.
I authorise [Company Name] and its appointed agency to verify the information I have provided, by contacting the institutions, previous employers and references listed by me, for the purpose of confirming my employment eligibility. I understand the results will be kept confidential and retained only as long as necessary.
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.