An insurance beneficiary form lets an employee designate or change the primary and contingent beneficiaries for their company-provided life and accident cover. Unlike a first-time nomination, it is built for updates after life events and records exactly what changed.
Group Personal Accident, Policy No. [Policy Number]
Voluntary Life Cover, Policy No. [Policy Number]
Type of Request
New designation (no earlier beneficiary on file)
Change of beneficiary, replacing designation dated [DD/MM/YYYY]
Removal of beneficiary: [Name]
Reason for Change
Marriage / Divorce / Birth or adoption / Death of beneficiary / Other
[Details]
Primary Beneficiaries
Name
Relationship
Date of Birth
Share (%)
[Beneficiary Name]
[Relationship]
[DD/MM/YYYY]
[%]
[Beneficiary Name]
[Relationship]
[DD/MM/YYYY]
[%]
Total
100%
Contingent Beneficiaries
Name
Relationship
Date of Birth
Share (%)
[Beneficiary Name]
[Relationship]
[DD/MM/YYYY]
[%]
[Beneficiary Name]
[Relationship]
[DD/MM/YYYY]
[%]
Total
100%
Declaration
I revoke all earlier beneficiary designations for the policies ticked above and designate the persons named in this form. I understand that any payment will be made according to the policy terms and applicable law, and that a minor beneficiary's share will be paid through an appointee or guardian.
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Frequently asked questions
What is a contingent beneficiary?+
A contingent beneficiary receives the benefit only if all primary beneficiaries have died before the employee. It avoids delays when the primary beneficiary is no longer alive.
How do I change the beneficiary on my group insurance?+
Fill in a beneficiary change form, have it witnessed, and submit it to HR. The latest acknowledged form replaces earlier designations.
Does a beneficiary change affect my PF nominee?+
No. PF and EPS nominations are changed separately through the EPFO process.
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.
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)