Free form template · Word

Group Medical Insurance Enrollment

This group medical insurance (GMC) enrollment form collects the member data an insurer or TPA needs to issue e-cards: the employee, each covered family member, the sum insured tier and any voluntary top-up. HR sends the compiled data to the insurer as an addition endorsement.

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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

Name (as per ID)	Relationship	Date of Birth	Gender	Pre-existing Illness (if any)
[Employee Name]	Self	[DD/MM/YYYY]	[M/F]	[Details / None]
[Member Name]	Spouse	[DD/MM/YYYY]	[M/F]	[Details / None]
[Member Name]	Son / Daughter	[DD/MM/YYYY]	[M/F]	[Details / None]
[Member Name]	Father / Mother	[DD/MM/YYYY]	[M/F]	[Details / None]

4. Premium Deduction Consent

I agree that the employee share of premium for voluntary top-up and parental cover, amounting to ₹[Amount] per annum, may be deducted from my salary in one instalment / monthly instalments of ₹[Amount] (strike out whichever is not applicable). I understand that the premium is not refundable once the endorsement is issued, except as allowed by the insurer.

5. Declaration and Consent

I declare that the details above are correct and that I have disclosed all known illnesses of the members listed. I consent to [Company Name] sharing this information with the insurer, TPA and insurance broker solely for the purpose of administering the group policy. I understand that cover is subject to the policy terms, conditions and exclusions.

Employee
[Employee Name]
Date: [Date]

HR / Benefits Team
[HR Name]
Sent to insurer on: [Date]

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What this template includes

Policy reference, insurer and TPA name so the employee knows who issues the e-card
Member table with exact names and dates of birth, the most common cause of claim mismatch
Sum insured tier and family floater or individual basis
Pre-existing illness disclosure for each member
Voluntary parental or top-up cover with salary deduction consent
Consent to share health data with the insurer and TPA

When to use it

When a new group mediclaim policy is placed and the full employee census is needed
For each new joiner who must be added to the existing GMC policy
When employees are offered a choice of sum insured tiers or a top-up at renewal
When the broker asks for a fresh, verified member data file

How to customise this template

1Fill in the policy number, insurer, TPA and policy period from your policy schedule
2Edit the coverage tiers to match what your broker has quoted
3Mention whether maternity and newborn cover is included in your policy
4Add the TPA helpline and e-card download instructions at the end

HR tips

Names must match Aadhaar or PAN spelling to avoid cashless denial at the hospital
Ask employees to disclose pre-existing conditions honestly; group policies often cover them but non-disclosure causes disputes
Send additions to the insurer promptly; cover typically starts from the endorsement date stated by the insurer
Keep the member data file password-protected when emailing the broker

Coverage, waiting periods and exclusions are governed by the insurer's policy wording. Review this form with your broker and against your benefits policy before use.

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Frequently asked questions

Who is covered under group medical insurance?+

Typically the employee, spouse and up to two or more children; some policies also allow parents or parents-in-law. The exact family definition is in your policy schedule.

Does group health insurance cover pre-existing diseases?+

Many employer group policies cover pre-existing conditions from day one, but this depends on the policy terms negotiated by your company. Check with HR or the TPA.

When will I get my mediclaim e-card?+

After HR sends your enrollment to the insurer and the endorsement is processed, the TPA issues e-cards, usually downloadable from its app or portal.

All 50 employee benefits & insurance →

[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)

Form · Word

Group Insurance Nomination Form

Download .docx

[Company Logo][Company Name]
DEPENDENT INSURANCE ENROLLMENT FORM
Company:
[Company Name]
Policy:
Group Mediclaim, No. [Policy Number]
Enrollment Window:
[DD/MM/YYYY] to [DD/MM/YYYY]
Date:
[Date]
Employee Details
Employee Name
Employee ID
Department
Mobile Number
Current Coverage: Self only / Self + Family
Eligibility Summary (from policy)
- Spouse: legally wedded spouse, one at a time.
- Children: up to [Number] children, up to age [Age] years.
- Parents / Parents-in-law: either set, subject to premium of ₹[Amount] per person per year.
- Dependants may be added at joining, within [Number] days of a life event, or at renewal.
Dependants to be Enrolled
Form · Word
Dependent Insurance Enrollment
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]
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)
Form · Word
Health Insurance Claim 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

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

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

Form · Word

Employee Insurance Details Form

Download .docx

[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
Form · Word
Insurance Beneficiary Form
Download .docx

[Company Logo][Company Name]

REQUEST FOR ADDITION OF MEMBERS

Ref. No.:: [Reference Number]
Date:: [Date]

To,
[Insurer / Broker Name]
[Address]

Subject: Addition of members under Policy No. [Policy Number] – [Company Name]

Dear Sir/Madam,

Please add the following members to our group policy(ies) with effect from the dates mentioned below. Kindly adjust the applicable premium against our CD Account No. [Account Number] and share the endorsement copy and e-cards at the earliest.

Emp ID	Member Name	Relationship	Date of Birth	Gender	Effective Date	Policies (GMC/GTL/GPA)	Sum Insured (₹)
[Employee ID]	[Employee Name]	Self	[DD/MM/YYYY]	[M/F]	[Date of Joining]	[GMC, GTL, GPA]	[Amount]
[Employee ID]	[Member Name]	Spouse	[DD/MM/YYYY]	[M/F]	[DD/MM/YYYY]	[GMC]	[Amount]
[Employee ID]	[Member Name]	Child	[DD/MM/YYYY]	[M/F]	[DD/MM/YYYY]	[GMC]	[Amount]
[Employee ID]	[Employee Name]	Self	[DD/MM/YYYY]	[M/F]	[Date of Joining]	[GMC, GTL]	[Amount]

Summary

Form · Word

Employee Insurance Addition Request

Download .docx

Group Medical Insurance Enrollment

Preview of the form

1. Primary Member (Employee)

2. Coverage Selection

3. Family Members to be Covered

4. Premium Deduction Consent

5. Declaration and Consent

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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