Free form template · Word

Fuel Reimbursement Form

A fuel reimbursement form lets employees who use their own two-wheeler or car for official travel claim fuel costs, either at a per-kilometre rate from a trip log or against fuel bills up to a cap. It is widely used for sales, service and field staff.

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[Company Logo][Company Name]

FUEL / CONVEYANCE REIMBURSEMENT CLAIM

Company:: [Company Name]
Claim Month:: [Month / Year]
Claim No.:: [Reference Number]
Date:: [Date]

Employee and Vehicle

Employee Name
Employee ID
Department
Territory / Beat
Vehicle Type: Two-wheeler / Car
Registration Number
Owned by: Self / Family
Driving Licence Valid till
Vehicle Insurance Valid till

Method

Per-km method: two-wheeler ₹[Amount]/km, car ₹[Amount]/km
Fuel bill method: actual bills up to ₹[Amount] per month

Trip Log

Date	From	To	Purpose / Customer	Opening km	Closing km	Distance (km)
[DD/MM/YYYY]	[Office]	[Location]	[Customer Name]	[km]	[km]	[km]
[DD/MM/YYYY]	[Location]	[Location]	[Purpose]	[km]	[km]	[km]
[DD/MM/YYYY]	[Location]	[Office]	[Purpose]	[km]	[km]	[km]
					Total	[km]

Claim Summary

Total km	Rate (₹/km) or Bills Total (₹)	Tolls and Parking (₹)	Amount Claimed (₹)	Admissible after Cap (₹)
[km]	[Amount]	[Amount]	[Amount]	[Amount]

Declaration

I certify that the trips listed were made for official purposes using the vehicle stated, that distances are recorded correctly, and that I hold a valid driving licence and vehicle insurance.

Employee
[Employee Name]
Date: [Date]

Verified and Approved by
[Reporting Manager]
Date: [Date]

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What this template includes

Vehicle details: type, registration number, ownership
Choice of per-km rate or fuel bill method
Trip-wise log with from, to, purpose and km
Odometer readings where required
Monthly cap and admissible amount
Manager verification of trips

When to use it

Field sales and service staff visiting customers on their own vehicles
Employees with a fuel component in flexi benefits
Occasional official trips such as bank or government office visits
Monthly settlement of local conveyance

How to customise this template

1Enter your per-km rates for two-wheelers and cars
2Decide whether odometer readings or GPS app logs are needed
3Set a monthly cap by role
4Add tolls and parking if reimbursed separately

HR tips

Require the purpose and customer name for each trip
Use a map check for unusually long trips
Ask for valid driving licence and insurance details once a year
Do not mix fuel claims with outstation travel claims

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Frequently asked questions

How is fuel reimbursement calculated?+

Either by multiplying official kilometres by a fixed per-km rate, or by reimbursing fuel bills up to a monthly cap. Your company chooses the method.

Do I need fuel bills for a per-km claim?+

Usually not, but you must submit a trip log and may need odometer readings.

Is commuting to office covered under fuel reimbursement?+

Normally no; only official trips beyond regular commuting are covered unless your policy says otherwise.

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Annual Limit (₹)	Claimed So Far (₹)	This Claim (₹)	Balance After Claim (₹)
[Amount]	[Amount]	[Amount]	[Amount]

[Company Logo][Company Name]

MOBILE REIMBURSEMENT CLAIM

Company:: [Company Name]
Claim Month / Quarter:: [Period]
Claim No.:: [Reference Number]
Date:: [Date]

Employee Details

Employee Name
Employee ID
Grade
Department
Registered Mobile Number
Monthly Limit: ₹[Amount]

Bill / Recharge Details

Mobile No.	Operator	Postpaid / Prepaid	Bill or Recharge Date	Period Covered	Amount (₹)
[Mobile No.]	[Operator]	[Postpaid]	[DD/MM/YYYY]	[Month]	[Amount]
[Mobile No.]	[Operator]	[Prepaid]	[DD/MM/YYYY]	[28 days]	[Amount]
[Mobile No.]	[Operator]	[Prepaid]	[DD/MM/YYYY]	[28 days]	[Amount]
				Total Billed	[Amount]

Claim Calculation

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[Company Logo][Company Name]
INTERNET REIMBURSEMENT CLAIM (WORK FROM HOME)
Company:
[Company Name]
Claim Period:
[Month]
Claim No.:
[Reference Number]
Date:
[Date]
Employee Details
Employee Name
Employee ID
Department
Work Arrangement: Remote / Hybrid
Registered Home Address
Connection Details
Internet Service Provider
Plan Speed (Mbps)
Billing Cycle: Monthly / Quarterly / Annual
Account Holder Name
Relationship (if not self)
Claim Details
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[Company Logo][Company Name]
EXPENSE REIMBURSEMENT CLAIM
Company:
[Company Name]
Claim No.:
[Reference Number]
Claim Period:
[Month]
Date:
[Date]
Claimant
Employee Name
Employee ID
Department
Cost Centre / Project Code
Reporting Manager
Expense Categories
- C1 Client entertainment
- C2 Courier and postage
- C3 Stationery and printing
- C4 Software and subscriptions (pre-approved)
- C5 Team supplies and refreshments
- C6 Other (specify)
Expense Details
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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
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Internet Service Provider
Plan Speed (Mbps)
Billing Cycle: Monthly / Quarterly / Annual
Account Holder Name
Relationship (if not self)

Annual Entitlement (₹)	Claimed till Last Quarter (₹)	This Claim (₹)	Balance (₹)
[Amount]	[Amount]	[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]

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

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[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)

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Employee Name
Employee ID
Department
Cost Centre / Project Code
Reporting Manager

Fuel Reimbursement Form

Preview of the form

Employee and Vehicle

Method

Trip Log

Claim Summary

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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