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Employee Nominee Declaration Form

An employee nominee declaration form lets an employee name who should receive unpaid salary, leave encashment, reimbursements and other company dues if the employee dies while in service. It covers company dues that are not governed by separate statutory nomination forms.

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Preview of the form

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[Company Logo][Company Name]

NOMINEE DECLARATION FORM (COMPANY DUES)

Employee Name:
[Employee Name]
Employee ID:
[Employee ID]
Designation:
[Designation]
Date of Joining:
[Date of Joining]

1. Scope of Nomination

This nomination covers amounts payable by [Company Name] in the event of my death while in service, including unpaid salary, leave encashment, pending reimbursements, performance bonus or incentive due, and any other company benefit not covered by a separate statutory nomination.

2. Nominee Details

Nominee NameRelationshipDate of BirthAddressShare (%)
[Nominee Name][Relationship][DD/MM/YYYY][Address][%]
[Nominee Name][Relationship][DD/MM/YYYY][Address][%]
[Nominee Name][Relationship][DD/MM/YYYY][Address][%]

3. Guardian Details (if any nominee is a minor)

Name of Guardian
Relationship with Minor
Address and Mobile Number

4. Declaration

I hereby nominate the person(s) named above to receive the amounts described in Section 1 in the shares stated. This nomination cancels any earlier company-dues nomination made by me. I understand I may change it by submitting a fresh form.

Signature of Employee
[Employee Name]
Date: [Date]
Place: [Work Location]

5. Witnesses

Witness 1
Name
Address
Signature
Witness 2
Name
Address
Signature

HR Acknowledgement

Received and recorded on [Date].

Verified by
[HR Name]
HR Department, [Company Name]
Date: [Date]

What this template includes

  • Scope listing the dues covered, so it does not conflict with statutory nominations
  • Multiple nominees with percentage shares totalling 100%
  • Guardian details for minor nominees
  • Revocation of earlier nominations
  • Two witnesses for evidentiary value
  • HR acknowledgement with date of receipt

When to use it

  • At joining, along with PF and gratuity nominations
  • When an employee marries, has a child or loses a nominee
  • When the company introduces new benefits such as a superannuation or bonus scheme
  • During an annual nomination refresh

How to customise this template

  1. 1List exactly which company dues and benefits the nomination covers
  2. 2Add a contingent nominee row if your policy allows
  3. 3Include employee code in the footer of each page
  4. 4Keep separate statutory nominations for PF, gratuity and insurance

HR tips

  • Check that shares add up to 100%
  • Ask for a fresh nomination after marriage
  • Witnesses should not be nominees
  • Return a signed acknowledgement copy to the employee

This template is a starting point for company dues only; statutory nominations for PF, gratuity, ESI and insurance must be made in their prescribed formats. Review it against applicable labour laws, state rules, your company's standing orders and policies, and with a legal adviser where needed.

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Frequently asked questions

What is an employee nominee declaration?+

It is a written nomination by which an employee names the persons who will receive company dues such as unpaid salary and leave encashment in case of death during service.

Can an employee change the nominee later?+

Yes. The employee can submit a fresh form at any time, which revokes the earlier nomination from the date HR receives it.

Does this replace PF and gratuity nomination?+

No. PF, gratuity, ESI and insurance have their own nomination processes, which must be completed separately.