Free form template · Word

Group Insurance Nomination Form

A group insurance nomination form records whom an employee wants the death benefit under the company's group term life (GTL) or group personal accident (GPA) policy paid to. HR collects it at joining and keeps it on file so a claim can be settled quickly if the worst happens.

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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)

Appointee Name
Relationship to Minor Nominee
Address
Mobile Number
Appointee Signature

Declaration

I, [Employee Name], hereby nominate the person(s) named above to receive the amount payable under the group insurance policy(ies) of [Company Name] in the event of my death, in the shares indicated. This nomination cancels any earlier nomination made by me for these policies. I understand that payment will be made as per the policy terms and applicable law.

Employee
[Employee Name]
Date: [Date]

Witness 1
Name: [Witness Name]
Address: [Address]

Witness 2
Name: [Witness Name]
Address: [Address]

For HR use: Received on [Date] by [HR Name]. Previous nomination dated [DD/MM/YYYY] marked superseded.

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What this template includes

Policy types covered by the nomination, GTL, GPA or both
Nominee table with relationship and percentage share totalling 100%
Appointee details where a nominee is a minor
Revocation line confirming this form replaces earlier nominations
Two witness signatures to support authenticity
HR receipt with date so the latest version is clear

When to use it

At onboarding when the employee is auto-enrolled in GTL or GPA cover
After marriage, divorce, birth of a child or death of an existing nominee
During an annual nomination audit when records are found missing
When the company moves to a new group life insurer

How to customise this template

1Name the group policies and insurers your company holds
2Add the employee's cover amount, for example a multiple of CTC, if you want it visible
3Include a contact number field for each nominee to speed up claims
4Decide whether HR or the insurer holds the original and state it

HR tips

Check that shares add up to exactly 100% before accepting the form
Always ask for an appointee when a child is named
Remind employees that this nomination is separate from PF, EPS and gratuity nominations
Run a yearly reminder so nominations stay current after life events

Rights of nominees are governed by insurance law and the policy terms. Treat this as a starting point and review with your insurer or legal adviser.

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Frequently asked questions

Is a group insurance nomination the same as a PF nomination?+

No. PF, EPS and gratuity have their own statutory nomination forms. The group insurance nomination applies only to the company's group life or accident policy.

Can I nominate more than one person?+

Yes, you can name several nominees and specify each person's percentage share, as long as the total is 100%.

Why is an appointee needed?+

If a nominee is a minor, the appointee receives the claim amount on the minor's behalf until they become an adult.

All 50 employee benefits & insurance →

[Company Logo][Company Name]
LIFE INSURANCE NOMINATION FORM
Company:
[Company Name]
Policy:
Group Term Life, No. [Policy Number]
Insurer:
[Insurer Name]
Date:
[Date]
Employee Details
Employee Name
Employee ID
Designation
Date of Birth
Date of Joining
Cover Basis [Number] x Annual CTC / Flat ₹[Amount]
Current Sum Assured: ₹[Amount]
Nominees
Nominee Name Relationship Age Address Share (%)
[Nominee Name] [Relationship] [Age] [Address] [%]
[Nominee Name] [Relationship] [Age] [Address] [%]
[Nominee Name] [Relationship] [Age] [Address] [%]
Appointee for Minor Nominee
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[Company Logo][Company Name]
GROUP MEDICAL INSURANCE (GMC) ENROLLMENT FORM
Policyholder:
[Company Name]
Insurer:
[Insurer Name]
TPA:
[TPA Name]
Policy No.:
[Policy Number]
Policy Period:
[DD/MM/YYYY] to [DD/MM/YYYY]
1. Primary Member (Employee)
Employee Name (as per ID proof)
Employee ID
Date of Birth
Gender
Date of Joining
Work Location
Mobile Number
Email ID
2. Coverage Selection
Sum Insured Tier: ₹[Amount] / ₹[Amount] / ₹[Amount]
Basis: Family Floater / Individual
Voluntary Top-up: Yes / No, Sum Insured ₹[Amount]
Parental Cover: Parents / Parents-in-law / None
3. Family Members to be Covered
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Group Medical Insurance Enrollment
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[Company Logo][Company Name]
HEALTH INSURANCE CLAIM SUBMISSION FORM (INTERNAL)
Company:
[Company Name]
Insurer / TPA:
[Insurer Name] / [TPA Name]
Policy No.:
[Policy Number]
Internal Claim Ref.:
[Reference Number]
Date of Submission:
[Date]
Important: This form helps HR process your claim. The insurer's or TPA's official claim form must also be completed, signed and attached where required.
1. Employee Details
Employee Name
Employee ID
Department
Mobile Number
Email ID
2. Patient Details
Patient Name
Relationship to Employee
Age
E-card / Member ID
TPA Claim Intimation No. (if any)
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Health Insurance Claim Form
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[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
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Nominee Name	Relationship	Age	Address	Share (%)
[Nominee Name]	[Relationship]	[Age]	[Address]	[%]
[Nominee Name]	[Relationship]	[Age]	[Address]	[%]
[Nominee Name]	[Relationship]	[Age]	[Address]	[%]

Employee Name (as per ID proof)
Employee ID
Date of Birth
Gender
Date of Joining
Work Location
Mobile Number
Email ID

Sum Insured Tier: ₹[Amount] / ₹[Amount] / ₹[Amount]
Basis: Family Floater / Individual
Voluntary Top-up: Yes / No, Sum Insured ₹[Amount]
Parental Cover: Parents / Parents-in-law / None

Patient Name
Relationship to Employee
Age
E-card / Member ID
TPA Claim Intimation No. (if any)

[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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[Company Logo][Company Name]
INSURANCE BENEFICIARY DESIGNATION / CHANGE FORM
Company:
[Company Name]
Form Ref.:
[Reference Number]
Date:
[Date]
Effective From:
[DD/MM/YYYY]
Employee Details
Employee Name
Employee ID
Department
Designation
Mobile Number
Policies Affected
- Group Term Life, Policy No. [Policy Number]
- Group Personal Accident, Policy No. [Policy Number]
- Voluntary Life Cover, Policy No. [Policy Number]
Type of Request
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Insurance Beneficiary Form
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[Company Logo][Company Name]
PERSONAL ACCIDENT CLAIM FORM (INTERNAL)
Company:
[Company Name]
GPA Policy No.:
[Policy Number]
Insurer:
[Insurer Name]
Internal Ref.:
[Reference Number]
Date:
[Date]
This form supports HR in filing the claim. The insurer's official claim form must also be completed and signed by the insured or claimant.
1. Insured Employee
Employee Name
Employee ID
Designation
Department
Date of Birth
2. Claimant (if not the employee)
Claimant Name
Relationship to Employee
Nominee as per records: Yes / No
Mobile Number
Address
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Accident Insurance Claim Form
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