Free form template · Word

Employee Welfare Assistance Form

An employee welfare assistance form is a request for one-time financial or practical help from the company or its welfare fund during a hardship, such as a medical emergency, death in the family or a natural calamity. It describes the need, the support sought and supporting documents, and records the committee's decision.

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[Company Logo][Company Name]

EMPLOYEE WELFARE ASSISTANCE REQUEST

Company:: [Company Name]
Request No.:: [Reference Number]
Date:: [Date]
Handling:: Confidential

Applicant

Employee Name (or family member applying on behalf)
Employee ID
Department
Years of Service
Mobile Number

Nature of Hardship

Medical emergency (self or dependant)
Death in the family
Natural calamity / fire / accident to property
Other serious hardship: [Details]

Details of Need

Brief description
Total cost involved (₹)
Amount covered by insurance / other sources (₹)
Assistance requested (₹)
Type: Grant / Interest-free advance / Either
Other help needed: Leave / Counselling / Logistics

Documents Attached

Hospital estimate or bills
Insurance settlement or denial letter
Death certificate (if applicable)
Photographs or official report of damage (if applicable)

Declaration

I declare that the information above is true. I understand that assistance is discretionary, decided as per the welfare policy and available funds. If an advance is sanctioned, I agree to repay it as per the schedule communicated and authorise recovery from my salary.

Applicant
[Employee Name]
Date: [Date]

Committee Decision

Recommended By	Type Sanctioned	Amount Sanctioned (₹)	Date Paid	Remarks
[HR Name]	[Grant / Advance]	[Amount]	[DD/MM/YYYY]	[Remarks]

Approved by
[Authorised Signatory]
Date: [Date]

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What this template includes

Nature of hardship with category
Amount needed and what other help is available, such as insurance
Choice of grant or interest-free advance
Supporting documents
Committee recommendation and sanctioned amount
Confidential handling statement

When to use it

A family member's treatment exceeds insurance cover
An employee's home is damaged by flood or fire
Funeral and related expenses after a bereavement
A colleague's family needs support after the employee's death

How to customise this template

1Set maximum grant amounts by category
2Name the committee or authority that decides
3Add a fast-track route for medical emergencies
4Link to your employee loan form for repayable support

HR tips

Handle requests discreetly and quickly
Ask only for documents needed to verify the need
Record decisions and reasons consistently
Offer non-financial help too, such as leave or EAP

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Frequently asked questions

Can my company give me financial help in an emergency?+

Many companies offer emergency grants or interest-free advances through a welfare fund or HR policy. Use the welfare assistance form to apply.

Is welfare assistance repayable?+

Grants are usually not repayable; advances are recovered from salary in instalments. The form lets you indicate which you need.

Who decides welfare assistance requests?+

Typically a welfare committee or HR head, based on the policy and fund balance.

All 50 employee benefits & insurance →

[Company Logo][Company Name]
EMPLOYEE ASSISTANCE PROGRAMME (EAP) REQUEST FORM
Company:
[Company Name]
EAP Provider:
[Provider Name]
24x7 Helpline:
[Phone Number]
Date:
[Date]
Confidentiality: Your request goes to [Provider Name]. The company receives only anonymous, aggregated usage data. Information is shared only with your consent or where there is a serious risk to safety. If you are in immediate danger, call [Emergency Number] or go to the nearest hospital.
Who Needs Support
Name of Person Seeking Support
Relationship to Employee: Self / Spouse / Child / Parent
Employee ID (for eligibility check only)
City
Type of Support
- Emotional wellbeing and counselling
- Work stress or relationship at work
- Family or relationship concerns
- Legal information and guidance
- Financial and debt guidance
- Childcare or eldercare information
- Grief or critical incident support
Form · Word
Employee Assistance Program Form
Download .docx
[Company Logo][Company Name]
EMPLOYEE WELFARE FUND MEMBERSHIP FORM
Fund:
[Company Name] Staff Welfare Fund
Managed by:
Welfare Committee, [Work Location]
Form No.:
[Reference Number]
Date:
[Date]
Member Details
Employee Name
Employee ID
Department
Designation
Date of Joining
Mobile Number
Contribution
Contribution Option Employee (₹/month) Company Matching (₹/month) Select
Basic [Amount] [Amount] [ ]
Standard [Amount] [Amount] [ ]
Enhanced [Amount] [Amount] [ ]
Purposes the Fund May Support
Form · Word
Employee Welfare Fund 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
[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

Name of Person Seeking Support
Relationship to Employee: Self / Spouse / Child / Parent
Employee ID (for eligibility check only)
City

Contribution Option	Employee (₹/month)	Company Matching (₹/month)	Select
Basic	[Amount]	[Amount]	[ ]
Standard	[Amount]	[Amount]	[ ]
Enhanced	[Amount]	[Amount]	[ ]

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]

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

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Employee Insurance Details Form

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

[Company Logo][Company Name]

EMPLOYEE WELLNESS PROGRAM: NEEDS AND INTEREST FORM

Company:: [Company Name]
Survey Period:: [DD/MM/YYYY] to [DD/MM/YYYY]
Coordinator:: [HR Name]

We are planning our wellness calendar for [Year]. Your answers will help us choose activities that suit you. Questions about health are optional and responses will be reported only in aggregate.

About You (optional)

Name (optional)
Department
Work Location
Work Pattern: General Shift / Rotational Shift / Remote / Hybrid
Age Group: Under 25 / 25-34 / 35-44 / 45-54 / 55+

Rate Your Interest (1 = low, 5 = high)

Programme	Interest (1-5)	Preferred Format
Yoga and stretching	[1-5]	[On-site / Online]
Gym or fitness challenge	[1-5]	[On-site / App]
Nutrition and diet talks	[1-5]	[On-site / Online]
Stress management and mental health	[1-5]	[On-site / Online]
Sleep and lifestyle workshops	[1-5]	[Online]
Financial wellness (tax, savings)	[1-5]	[Online]
Preventive health check-up	[1-5]	[On-site / Lab]

Form · Word

Employee Wellness Program Form

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[Company Logo][Company Name]

FLEXIBLE BENEFITS SELECTION FORM

Company:: [Company Name]
Financial Year:: [FY 20XX-XX]
Submission Date:: [Date]
Payroll Cut-off:: [DD/MM/YYYY]

Part 1: Employee Information

Employee Name
Employee ID
Designation
Department
Annual CTC: ₹[CTC]
Annual Flexi Basket: ₹[Amount]
Tax Regime Opted: Old / New

Part 2: Allocation of Flexi Basket

Component	Company Limit per Month (₹)	My Monthly Allocation (₹)	Annual Allocation (₹)	Bills Required
Meal Card / Food Coupons	[Amount]	[Amount]	[Amount]	No (card based)
Fuel and Vehicle Maintenance	[Amount]	[Amount]	[Amount]	Yes
Telephone and Internet	[Amount]	[Amount]	[Amount]	Yes
Leave Travel Allowance	[Amount]	[Amount]	[Amount]	Yes, travel proof
Books and Periodicals	[Amount]	[Amount]	[Amount]	Yes
Employer NPS Contribution	[Amount]	[Amount]	[Amount]	No
Total (must equal flexi basket)	-	[Amount]	[Amount]	-

Part 3: Terms

Form · Word

Benefits Selection Form

Download .docx

Employee Welfare Assistance Form

Preview of the form

Applicant

Nature of Hardship

Details of Need

Documents Attached

Declaration

Committee Decision

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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