Free form template · Word

Health Checkup Registration

A health checkup registration form books employees into the company's annual preventive health checkup or an on-site health camp. It captures package choice, appointment slot and who may see the report, so the diagnostic partner can schedule and the employee's medical results stay confidential.

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[Company Logo][Company Name]

ANNUAL HEALTH CHECKUP REGISTRATION

Company:: [Company Name]
Diagnostic Partner:: [Partner Name]
Checkup Window:: [DD/MM/YYYY] to [DD/MM/YYYY]
Coordinator:: [HR Name]

Employee Details

Employee Name
Employee ID
Department
Work Location
Date of Birth
Gender
Mobile Number
Email ID

Package Selection

Package	Eligible Age Group	Key Tests	Cost to Employee (₹)	Select
Basic	Below 35	[CBC, blood sugar, lipid profile, urine]	Nil	[ ]
Comprehensive	35 and above	[Basic + thyroid, liver, kidney, ECG]	Nil	[ ]
Women's Health Add-on	All	[Tests as per partner]	[Amount]	[ ]
Spouse / Parent Package	All	[As per package]	[Amount]	[ ]

Appointment Preference

Mode: Diagnostic Centre / Home Sample Collection / On-site Camp
Preferred Centre / Address
Preferred Date
Preferred Slot: 7-9 am / 9-11 am

Instructions

Fast for the period advised by the partner before blood tests; water is usually allowed.
Carry your employee ID card and a photo ID.
Inform the centre about any regular medication.
Reports will be emailed directly to you within the partner's stated timeline.

Consent

I voluntarily register for the health checkup. I agree that my reports will be shared only with me, and that [Company Name] will receive only attendance information. For family add-ons, I authorise deduction of ₹[Amount] from my salary.

Employee
[Employee Name]
Date: [Date]

HR
[HR Name]
Appointment Confirmed: [DD/MM/YYYY]

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What this template includes

Package choice linked to age group
Spouse or parent add-on with cost recovery
Appointment slot and centre or home collection
Pre-test instructions such as fasting
Report confidentiality: sent to employee only
Separate note for mandatory role-based medicals

When to use it

Annual preventive health checkup offered as a benefit
On-site health camps run with a diagnostic partner
When the group policy includes a free checkup for members
Periodic medical examinations required for specific roles

How to customise this template

1List the actual packages and tests your diagnostic partner offers
2Insert centre addresses for each city
3Set the add-on rate for family members
4Remove the mandatory section if all checkups are voluntary

HR tips

Reports should go directly to the employee unless a role-based medical requires fitness certification
Send fasting reminders the evening before
Offer slots across shifts so plant staff can attend
Track attendance, not results, for benefit utilisation reports

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Frequently asked questions

Will my employer see my health checkup report?+

For voluntary preventive checkups, reports are usually sent only to the employee. For role-based fitness medicals, the employer may receive a fit or unfit certificate as per policy.

Can family members join the company health checkup?+

Many companies allow spouse or parents at a discounted rate recovered from salary. Check the add-on section.

Do I need to fast before the health checkup?+

Most packages with blood sugar and lipid tests require fasting, typically overnight. Follow the instructions from the diagnostic partner.

All 50 employee benefits & insurance →

[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]
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]
CANTEEN REGISTRATION FORM
Company / Unit:
[Company Name], [Work Location]
Canteen Contractor:
[Contractor Name]
Effective From:
[DD/MM/YYYY]
Date:
[Date]
Employee Details
Employee Name
Employee ID / Token No.
Department
Shift: General / A / B / C
Mobile Number
Meal Plan
Meal Timing Subsidised Rate (₹) Opt (Y/N)
Breakfast [HH:MM-HH:MM] [Amount] [Y/N]
Lunch [HH:MM-HH:MM] [Amount] [Y/N]
Evening Tea and Snacks [HH:MM-HH:MM] [Amount] [Y/N]
Dinner (night shift) [HH:MM-HH:MM] [Amount] [Y/N]
Food Preference
Form · Word
Canteen Registration Form
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

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

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]	[ ]

Meal	Timing	Subsidised Rate (₹)	Opt (Y/N)
Breakfast	[HH:MM-HH:MM]	[Amount]	[Y/N]
Lunch	[HH:MM-HH:MM]	[Amount]	[Y/N]
Evening Tea and Snacks	[HH:MM-HH:MM]	[Amount]	[Y/N]
Dinner (night shift)	[HH:MM-HH:MM]	[Amount]	[Y/N]

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

Form · Word

Benefits Selection Form

Download .docx

[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
Form · Word
Group Medical Insurance Enrollment
Download .docx

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

[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]
MEDICLAIM DECLARATION
Company:
[Company Name]
Policy Year:
[DD/MM/YYYY] to [DD/MM/YYYY]
Date:
[Date]
A. Employee Particulars
Employee Name
Employee ID
Department
Designation
Date of Birth
Contact Number
B. Choice of Cover (tick one)
- I opt IN to the group mediclaim for myself and the dependants listed in Part C.
- I opt IN for myself only.
- I opt OUT of the group mediclaim. I am covered under policy no. [Policy Number] with [Insurer Name]. I understand I cannot claim under the company policy and may rejoin only at renewal, if permitted.
C. Dependants Declared for this Policy Year
Form · Word
Mediclaim Declaration Form
Download .docx

Employee Name
Employee ID / Token No.
Department
Shift: General / A / B / C
Mobile Number

Health Checkup Registration

Preview of the form

Employee Details

Package Selection

Appointment Preference

Instructions

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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