Free form template · Word

Employee Insurance Details Form

An employee insurance details form is a single summary record of every insurance and statutory cover an employee holds through the company: group health, term life, accident, ESI and any top-ups, with policy numbers and nominees. HR keeps it updated so it can answer queries and act quickly in emergencies.

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[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

ESI Applicable: Yes / No
ESI IP Number
Dispensary / Branch Office
UAN

Covered Dependants

Name	Relationship	Date of Birth	Member ID
[Dependant Name]	[Relationship]	[DD/MM/YYYY]	[Member ID]
[Dependant Name]	[Relationship]	[DD/MM/YYYY]	[Member ID]
[Dependant Name]	[Relationship]	[DD/MM/YYYY]	[Member ID]

Nominee and Emergency Contact

Nomination form on file dated
Primary Nominee Name
Emergency Contact Name and Relationship
Emergency Contact Mobile

Declaration

I have reviewed the details above and confirm they are correct. I will inform HR of any change in my dependants, nominees or contact details.

Employee
[Employee Name]
Date: [Date]

Verified by
[HR Name]
Human Resources

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What this template includes

Coverage summary table across all policy types
ESI coverage status and IP number for eligible employees
E-card and member IDs for quick hospital use
Nominee reference for life and accident cover
Emergency contact who knows how to use the cover
Last-updated date and HR verification

When to use it

To build or clean up an insurance master record for each employee
When a client or auditor asks for proof of employee coverage
When an employee needs a one-page summary of their cover for family members
During policy migration to a new insurer

How to customise this template

1List all the policies your company currently holds
2Add a workmen's compensation row if your company has an EC policy
3Pre-fill policy numbers before sending to employees to verify
4Set a review cycle such as every renewal

HR tips

Encourage employees to share the summary with a family member
Update the record the same day an addition or deletion is endorsed
Keep it separate from the personnel file's medical documents
Do not duplicate full nominee forms here, just reference them

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Frequently asked questions

Why does HR need an insurance details form?+

It gives HR one place to see all cover an employee has, which speeds up claims, audits and emergency support.

Are ESI and group mediclaim both applicable?+

Employees earning up to ₹21,000 a month in covered establishments come under ESI. Companies may also extend group mediclaim to them as an additional benefit as per policy.

How often should insurance details be updated?+

Whenever there is a change in dependants or nominees, and at least at each policy renewal.

All 50 employee benefits & insurance →

Form · Word
Employee Insurance Correction 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

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

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 Details Form

Preview of the form

Employee Information

Coverage Summary

Statutory Coverage

Covered Dependants

Nominee and Emergency Contact

Declaration

What this template includes

When to use it

How to customise this template

HR tips

Frequently asked questions

Employee Details

Member Whose Data Needs Correction

Correction Details

Employee Insurance Correction Form

Section A: Employee Details

Section B: Statutory Benefits

Employee Benefits Enrollment Form

Employee Details

Nominee Details

Appointee (only if a nominee is a minor)

Group Insurance Nomination Form

1. Employee Details

2. Patient Details

Health Insurance Claim Form

Employee and Policy

Nature of Assistance Needed

Claim Summary

Insurance Claim Assistance Form

Employee Details

Policies Affected

Type of Request

Insurance Beneficiary Form

Subject: Addition of members under Policy No. [Policy Number] – [Company Name]

Summary

Employee Insurance Addition Request

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

Employee Insurance Deletion Request

Employee Insurance Details Form

Preview of the form

Employee Information

Coverage Summary

Statutory Coverage

Covered Dependants

Nominee and Emergency Contact

Declaration

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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