Free form template · Word

Employee Wellness Program Form

An employee wellness program form is a needs-and-interest survey HR runs before designing or refreshing a corporate wellness calendar. It asks which activities employees want, preferred timing and format, and voluntary health goals, so the budget goes to programmes people will actually join.

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[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]

Timing and Goals

Preferred day(s)
Preferred time: Before shift / Lunch / After shift / Weekend
Wellness goal I would like support with (optional)
What stops me from joining wellness activities today
Would you like family members to join some sessions? Yes / No

Consent

I understand that participation in the survey is voluntary and that my responses will be used only to plan wellness activities and reported in aggregate form.

Employee (optional)
[Employee Name]
Date: [Date]

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What this template includes

Interest rating across fitness, nutrition, mental health, sleep and financial wellness
Format preference: on-site, online, app-based
Preferred day and time slots, including shift workers
Voluntary health goals without asking for medical diagnoses
Barriers to participation
Consent for anonymous aggregate use

When to use it

Before planning the annual wellness calendar
When participation in existing wellness sessions is low
After moving to a hybrid model, to choose online versus on-site formats
When a new insurer or wellness vendor offers a menu of services

How to customise this template

1Replace the activity list with what your vendor can actually offer
2Add shift-specific time slots for plant or BPO teams
3Make the form anonymous if you want more candid answers
4Translate into local languages for blue-collar teams

HR tips

Keep health questions optional and general
Share the results summary and the plan that follows
Include family-friendly options if many employees want them
Run a short pulse survey after six months to compare

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Frequently asked questions

What should a wellness program survey ask?+

Which activities interest employees, preferred timing and format, goals they want support with and what stops them participating.

Should wellness surveys be anonymous?+

Anonymous surveys often get more honest answers. If you need names for sign-ups, use a separate registration form.

Can a wellness program be linked to group insurance?+

Some insurers include wellness services or apps with group policies. Check with your broker what is included.

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

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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Employee Insurance Correction Form
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[Company Logo][Company Name]
WELLNESS PROGRAMME REGISTRATION FORM
Programme:
[Programme Name]
Organised by:
[Company Name], HR
Dates:
[DD/MM/YYYY] to [DD/MM/YYYY]
Venue / Link:
[Venue]
Registration Closes:
[DD/MM/YYYY]
Participant Details
Employee Name
Employee ID
Department
Work Location
Mobile Number
Team Name (for challenges)
Batch Selection
Batch Days Time Seats Select
Morning [Mon, Wed, Fri] [7:00-7:45 am] [Number] [ ]
Lunch [Tue, Thu] [1:15-1:45 pm] [Number] [ ]
Evening / Online [Mon-Fri] [6:30-7:15 pm] [Number] [ ]
Fitness Readiness
Form · Word
Wellness Program Registration
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
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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
Form · Word
Employee Welfare Assistance Form
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Member Name (as currently on e-card)
Relationship
E-card / Member ID

Batch	Days	Time	Seats	Select
Morning	[Mon, Wed, Fri]	[7:00-7:45 am]	[Number]	[ ]
Lunch	[Tue, Thu]	[1:15-1:45 pm]	[Number]	[ ]
Evening / Online	[Mon-Fri]	[6:30-7:15 pm]	[Number]	[ ]

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

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

[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

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Employee Wellness Program Form

Preview of the form

About You (optional)

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

Timing and Goals

Consent

What this template includes

When to use it

How to customise this template

HR tips

Hire top talent from BetterJobs

Frequently asked questions

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