Free form template · Word

ESIC Details Update Form

An ESIC details update form is used by employees covered under ESI to change their dispensary, add family members, correct personal details or update address in their insured person record. HR uses it to make the change on the employer portal and track the e-Pehchan card update.

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[Company Logo][Company Name]

ESIC INSURED PERSON DETAILS UPDATE FORM

Employee Name:: [Employee Name]
Employee ID:: [Employee ID]
ESIC IP Number:: [IP Number]
Employer Code:: [ESIC Employer Code]

Type of Update

Change of dispensary
Addition of family member
Removal of family member
Correction of personal details
Change of address / mobile

Dispensary

Current Dispensary
New Dispensary (Self)
New Dispensary (Family)

Family Members

Name	Relationship	Date of Birth	Residing with IP (Y/N)	Add / Remove
[Name]	[Relationship]	[DD/MM/YYYY]	[Y/N]	[Add / Remove]
[Name]	[Relationship]	[DD/MM/YYYY]	[Y/N]	[Add / Remove]
[Name]	[Relationship]	[DD/MM/YYYY]	[Y/N]	[Add / Remove]

Corrections

Field to Correct
Correct Value
Proof Attached

HR Use

Wages within ESI coverage limit confirmed
Updated on ESIC employer portal on [Date]
Updated card / e-Pehchan details handed over on [Date]

Privacy notice: [Company Name] collects the details on this page only for updating your ESI insured person record and benefits. Access is limited to authorised HR staff, and the record will be kept for the duration of ESI coverage and the statutory period for records, after which it will be securely deleted or destroyed. You may ask HR to see or correct your data, consistent with the Digital Personal Data Protection Act, 2023.

Employee
[Employee Name]
Date: [Date]

HR
[HR Name]
Date: [Date]

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What this template includes

IP number and coverage status
Dispensary for self and family
Family member additions with relationship and residence
Personal detail corrections
Coverage check against the ESI wage limit
HR portal update record

When to use it

An employee moves house and needs a nearer dispensary
A new family member must be added for medical benefit
Name or date of birth in the IP record is wrong
An employee with an existing IP number joins from another employer

How to customise this template

1Add your ESIC employer code
2List nearby dispensaries for your work location
3Include a column for family member residence where rules need it
4Mention the contribution rate, 0.75 per cent employee and 3.25 per cent employer, in a note
5Add the date the updated card was given to the employee

HR tips

Confirm the employee's wages are within the ₹21,000 monthly coverage limit
Update dispensary details as soon as an address changes
Do not collect family IDs beyond what the portal asks for
Hand over the updated card and explain how to use it

ESI processes and forms can change. Check current ESIC requirements and consult your compliance adviser before relying on this template.

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Frequently asked questions

Who is covered under ESIC?+

Employees in covered establishments earning up to ₹21,000 per month are generally covered.

How can I change my ESIC dispensary?+

Submit this form with your new address; HR will update the dispensary on the employer portal.

Can I add my parents under ESIC?+

Dependent parents may be added if they meet the eligibility conditions. HR will check before adding them.

All 50 employee personal & master records →

[Company Logo][Company Name]

PF MEMBER DETAILS CORRECTION REQUEST

Employee Name:: [Employee Name]
Employee ID:: [Employee ID]
UAN:: [UAN]
PF Member ID:: [Member ID]

Field	As per PF Record	Correct Detail	Proof Attached
Name	[As recorded]	[Correct]	[PAN / Masked Aadhaar]
Date of Birth	[DD/MM/YYYY]	[DD/MM/YYYY]	[Birth certificate / Class 10 certificate]
Father / Spouse Name	[As recorded]	[Correct]	[Proof]
Date of Joining	[DD/MM/YYYY]	[DD/MM/YYYY]	[Appointment letter]
Date of Exit (previous)	[DD/MM/YYYY]	[DD/MM/YYYY]	[Relieving letter]

Reason for the Mismatch
Online Request Number (if raised by employee)

HR Action Log

Date	Action	By	Status
[DD/MM/YYYY]	[Request verified]	[HR Name]	[Pending / Approved]
[DD/MM/YYYY]	[Submitted on employer portal]	[HR Name]	[Status]
[DD/MM/YYYY]	[Outcome communicated]	[HR Name]	[Status]

Privacy notice: [Company Name] collects the details on this page only for correcting your PF member record. Access is limited to authorised HR staff, and the record will be kept for the duration of employment and the statutory period for PF records, after which it will be securely deleted or destroyed. You may ask HR to see or correct your data, consistent with the Digital Personal Data Protection Act, 2023.

Form · Word

PF Details Update Form

Download .docx

[Company Logo][Company Name]

GROUP INSURANCE DETAILS UPDATE FORM

Employee Name:: [Employee Name]
Employee ID:: [Employee ID]
Grade:: [Grade]
Policy Year:: [DD/MM/YYYY] to [DD/MM/YYYY]

1. Current Cover (HR to pre-fill)

Policy	Sum Insured (₹)	Premium Paid by	Employee Choice
Group Medical Cover (GMC)	[Amount]	Company	[Continue / Change]
Group Term Life (GTL)	[Amount]	Company	[Continue]
Group Personal Accident (GPA)	[Amount]	Company	[Continue]
Voluntary Top-up	[Amount]	Employee	[Opt in / Opt out]

2. Members Covered under GMC

Name	Relationship	Date of Birth	Add / Retain / Remove
[Employee Name]	Self	[DD/MM/YYYY]	Retain
[Name]	[Relationship]	[DD/MM/YYYY]	[Action]
[Name]	[Relationship]	[DD/MM/YYYY]	[Action]

3. Nominee for GTL and GPA

Form · Word

Insurance Details Update Form

Download .docx

[Company Logo][Company Name]
EMPLOYEE CONTACT DETAILS FORM
Employee Name:
[Employee Name]
Employee ID:
[Employee ID]
Department:
[Department]
Date:
[Date]
Type of Submission
- New joiner
- Update to existing details
Phone and Email
Primary Mobile Number
Alternate Mobile Number (optional)
Personal Email ID
Official Email ID (HR to fill)
Addresses
Form · Word
Employee Contact Details Form
Download .docx

Primary Mobile Number
Alternate Mobile Number (optional)
Personal Email ID
Official Email ID (HR to fill)

[Company Logo][Company Name]

EMPLOYEE FAMILY DETAILS FORM

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

Please list only those family members who should be covered under a benefit. Leave the form blank if you do not wish to enrol anyone.

Sl.	Name of Family Member	Relationship	Date of Birth	Gender	Residing with Employee (Y/N)	Dependent (Y/N)	Purpose
1	[Name]	[Spouse]	[DD/MM/YYYY]	[Gender]	[Y/N]	[Y/N]	[Insurance / ESIC / Nomination]
2	[Name]	[Son / Daughter]	[DD/MM/YYYY]	[Gender]	[Y/N]	[Y/N]	[Purpose]
3	[Name]	[Relationship]	[DD/MM/YYYY]	[Gender]	[Y/N]	[Y/N]	[Purpose]
4	[Name]	[Relationship]	[DD/MM/YYYY]	[Gender]	[Y/N]	[Y/N]	[Purpose]

Benefits Selected

Group health insurance
ESIC family coverage (if wages within the ESI limit)
Use as reference for nominations

Privacy notice: [Company Name] collects the details on this page only for enrolling your family members in the benefits selected and supporting nominations. Access is limited to authorised HR staff, and the record will be kept for the period the benefit is active and the retention period thereafter, after which it will be securely deleted or destroyed. You may ask HR to see or correct your data, consistent with the Digital Personal Data Protection Act, 2023.

Form · Word

Employee Family Details Form

Download .docx

[Company Logo][Company Name]

DEPENDENT ADDITION / DELETION FORM

Employee Name:: [Employee Name]
Employee ID:: [Employee ID]
Policy No.:: [Policy Number]
Date:: [Date]

Action (Add / Remove / Change)	Dependant Name	Relationship	Date of Birth	Meets Policy Criteria (Y/N)	Proof Attached	Effective Date
[Add]	[Name]	[Child]	[DD/MM/YYYY]	[Y/N]	[Birth certificate]	[DD/MM/YYYY]
[Remove]	[Name]	[Relationship]	[DD/MM/YYYY]	[Y/N]	[NA]	[DD/MM/YYYY]
[Action]	[Name]	[Relationship]	[DD/MM/YYYY]	[Y/N]	[Proof]	[DD/MM/YYYY]

Reason for Change

Birth / adoption
Marriage
Dependant crossed age limit
Annual renewal choice
Death of dependant
Other: [Specify]

Premium Contribution (if applicable)

I authorise [Company Name] to recover ₹[Amount] per [month / year] from my salary towards the premium for the dependants added above, as per the company insurance policy.

Form · Word

Employee Dependent Details Form

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Form · Word
Emergency Contact Update Form
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[Company Logo][Company Name]
UAN DETAILS UPDATE FORM
Employee Name:
[Employee Name]
Employee ID:
[Employee ID]
Date of Joining:
[Date of Joining]
Establishment Code:
[PF Establishment Code]
Section 1: UAN Status (tick one)
- I have an existing UAN
- I have never been a PF member (new UAN required)
- I have more than one UAN
Section 2: Existing UAN Details
UAN
Previous Employer Name
Previous PF Member ID
Date of Exit from Previous Employer
UAN Activated (Yes / No)
Section 3: KYC Status on UAN
Form · Word
UAN Update Form
Download .docx

Name
Relationship
Mobile Number
Alternate Number
City
Language(s) spoken

Name
Relationship
Mobile Number
City

UAN
Previous Employer Name
Previous PF Member ID
Date of Exit from Previous Employer
UAN Activated (Yes / No)

[Company Logo][Company Name]

EDUCATION QUALIFICATION UPDATE FORM

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

New Qualification Details

Qualification (e.g. B.Com, MBA, Diploma)
Specialisation
University / Board
Institution / Study Centre
Mode (Regular / Part-time / Distance / Online)
Year of Passing
Grade / CGPA / Percentage
Certificate Number

Linked Benefit

No benefit claimed; profile update only
Education reimbursement claim (ref: [Reference Number])
Company-sponsored programme (agreement ref: [Reference Number])

Verification (HR use)

Form · Word

Education Qualification Update Form

Download .docx

ESIC Details Update Form

Preview of the form

Type of Update

Dispensary

Family Members

Corrections

HR Use

What this template includes

When to use it

How to customise this template

HR tips

Frequently asked questions

HR Action Log

PF Details Update Form

1. Current Cover (HR to pre-fill)

2. Members Covered under GMC

3. Nominee for GTL and GPA

Insurance Details Update Form

Type of Submission

Phone and Email

Addresses

Employee Contact Details Form

Benefits Selected

Employee Family Details Form

Reason for Change

Premium Contribution (if applicable)

Employee Dependent Details Form

Primary Emergency Contact

Secondary Emergency Contact

Optional Medical Alert

Emergency Contact Update Form

Section 1: UAN Status (tick one)

Section 2: Existing UAN Details

Section 3: KYC Status on UAN

UAN Update Form

New Qualification Details

Linked Benefit

Verification (HR use)

Education Qualification Update Form

ESIC Details Update Form

Preview of the form

Type of Update

Dispensary

Family Members

Corrections

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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