Free form template · Word

Employee Insurance Correction Form

An employee insurance correction form is used when member data on the group policy or e-card is wrong, such as a misspelt name, wrong date of birth or incorrect relationship. It shows the current and correct value side by side with proof so the insurer can issue a correction endorsement.

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[Company Logo][Company Name]

EMPLOYEE INSURANCE DATA CORRECTION FORM

Company:: [Company Name]
Policy No.:: [Policy Number]
Request Ref.:: [Reference Number]
Date:: [Date]

Employee Details

Employee Name
Employee ID
Department
Mobile Number
Planned hospitalisation in next 15 days: Yes / No

Member Whose Data Needs Correction

Member Name (as currently on e-card)
Relationship
E-card / Member ID

Correction Details

Field	Current Value (As Is)	Correct Value (To Be)	Proof Attached
Name	[Current]	[Correct]	[PAN / Passport / Birth Certificate]
Date of Birth	[DD/MM/YYYY]	[DD/MM/YYYY]	[Document]
Gender	[Current]	[Correct]	[Document]
Relationship	[Current]	[Correct]	[Document]

Declaration

I request correction of the details listed above and confirm that the corrected information matches the attached proof. I understand that the insurer may revise the premium if the correction changes the member's age band.

Employee
[Employee Name]
Date: [Date]

For HR Use

Step	Date	By
Sent to broker / insurer	[DD/MM/YYYY]	[HR Name]
Correction endorsement received	[DD/MM/YYYY]	[HR Name]
Revised e-card shared with employee	[DD/MM/YYYY]	[HR Name]

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What this template includes

As-is versus to-be table for each incorrect field
Member and e-card IDs to locate the record
Proof document reference for each correction
Urgency flag if hospitalisation is planned
Employee declaration that the corrected data is accurate
HR tracking of endorsement and new e-card issue

When to use it

An employee spots a spelling mistake on their or a dependant's e-card
A hospital raises a mismatch at the cashless desk
The date of birth on record differs from ID proof
Gender or relationship has been captured wrongly in the census

How to customise this template

1Add any extra fields your insurer stores, such as employee grade
2Insert the broker contact who handles corrections
3Set an internal turnaround target
4Attach your insurer's own correction format if it insists on one

HR tips

Fix errors immediately; mismatches are a common reason for cashless delays
Use the ID document the hospital will see as the source of truth
Do not change sum insured through a correction; that is a separate request
Ask the employee to download the revised e-card and discard the old one

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Frequently asked questions

How do I correct my name on a group mediclaim card?+

Submit a correction form with ID proof to HR. HR sends it to the insurer or TPA, which issues a correction endorsement and a new e-card.

Will a wrong date of birth affect my claim?+

It can cause verification delays or queries. Correct it as soon as you notice the error.

Is there a charge for correcting insurance details?+

Usually no, unless the correction changes the premium, for example an age band change. The insurer will advise.

All 50 employee benefits & insurance →

[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]
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 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
[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

Patient Name
Relationship to Employee
Age
E-card / Member ID
TPA Claim Intimation No. (if any)

[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

[Company Logo][Company Name]

REQUEST FOR DELETION OF MEMBERS

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

To,
[Insurer / Broker Name]
[Address]

Subject: Deletion of members from Policy No. [Policy Number] – [Company Name]

Dear Sir/Madam,

We request you to delete the following members from our group policy(ies) with effect from the dates stated. Kindly deactivate their e-cards and credit any refundable premium to our CD Account No. [Account Number].

Emp ID	Member Name	Relationship	Deletion Date	Reason	Claim Pending (Y/N)
[Employee ID]	[Employee Name]	Self + Family	[Last Working Day]	Resignation	[Y/N]
[Employee ID]	[Employee Name]	Self	[Last Working Day]	Termination / Retirement	[Y/N]
[Employee ID]	[Member Name]	Child	[DD/MM/YYYY]	Age limit crossed	[Y/N]
[Employee ID]	[Member Name]	Spouse	[DD/MM/YYYY]	No longer eligible	[Y/N]

Where a claim is marked as pending, please continue processing it for treatment taken during the period of cover. Employee [Employee Name] has requested information on portability or conversion; kindly contact them at [Mobile / Email].

Letter · Word

Employee Insurance Deletion Request

Download .docx

Employee Insurance Correction Form

Preview of the form

Employee Details

Member Whose Data Needs Correction

Correction Details

Declaration

For HR Use

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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