Free form template · Word

Insurance Claim Assistance Form

An insurance claim assistance form is how an employee asks HR to step in when a group insurance claim is delayed, rejected, partly settled or stuck at the cashless desk. HR uses it to brief the broker or insurer and track the escalation until closure.

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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

Hospital / Provider
Date of Admission or Event
Date Claim Filed
Amount Claimed (₹)
Amount Settled (₹)
Reason Given by TPA / Insurer
What I have done so far

Attachments

Copy of claim submission acknowledgement
TPA query / rejection / settlement letter
Copy of insurer claim form submitted
Any additional documents now available

HR Action Log

Date	Action Taken	With Whom	Outcome
[DD/MM/YYYY]	[Escalated to broker]	[Name]	[Outcome]
[DD/MM/YYYY]	[Follow-up with TPA]	[Name]	[Outcome]
[DD/MM/YYYY]	[Closure communicated]	[Employee Name]	[Outcome]

Consent

I request HR to assist with the claim described above and consent to HR sharing my claim details with the broker, TPA and insurer for this purpose. I understand that the final decision rests with the insurer under the policy terms.

Employee
[Employee Name]
Date: [Date]

HR / Benefits Team
[HR Name]
Closed on: [Date]

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What this template includes

Issue type selection so HR routes the request correctly
Claim number and TPA reference for quick lookup
Short description of what has happened so far
Amount claimed versus amount settled to show the gap
Urgency flag for in-hospital cases
HR action log with outcome and closure date

When to use it

A cashless approval is pending while the patient is still admitted
A reimbursement claim is delayed beyond the period the TPA communicated
A claim is rejected or settled for less and the employee wants a review
The TPA has raised a document query the employee does not understand

How to customise this template

1List your broker's escalation contacts and service timelines
2Add an emergency phone number for urgent cashless cases
3Link to the insurer's grievance process if internal escalation fails
4Decide who signs off closure, HR or the employee

HR tips

Attach the TPA's rejection or query letter; escalations without it stall
Treat in-hospital cases as same-day priority
Do not promise the employee a reversal; explain that the insurer decides as per policy
Use the log to spot repeat issues and raise them at renewal

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Frequently asked questions

What can I do if my group mediclaim claim is rejected?+

Ask HR to escalate through the broker with the rejection letter and any missing documents. If still unresolved, the insurer's grievance process is available to policyholders and members.

Can HR speed up cashless approval?+

HR and the broker can follow up with the TPA and insurer, especially for urgent admissions, but approval depends on the documents from the hospital and the policy terms.

Do I need to fill the insurer claim form again?+

Only if the TPA asks. This assistance form is an internal escalation request and does not replace the insurer's own forms.

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
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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
Form · Word
Accident Insurance Claim Form
Download .docx

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

Claimant Name
Relationship to Employee
Nominee as per records: Yes / No
Mobile Number
Address

[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

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[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

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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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Employee Insurance Correction Form
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[Company Logo][Company Name]
MEDICAL EXPENSE CLAIM FORM
Company:
[Company Name]
Claim No.:
[Reference Number]
Date:
[Date]
Claimant Details
Employee Name
Employee ID
Department
Work Location
ESI Covered: Yes / No
Reason for Claim (tick one)
- Minor injury at workplace, Incident Report No. [Reference Number]
- Company-mandated medical test (pre-employment / periodic / food handler)
- Vaccination required for official travel
- Medical treatment during official travel
- Other approved reason: [Details]
Incident or Requirement Details
Form · Word
Medical Expense Claim Form
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Member Name (as currently on e-card)
Relationship
E-card / Member ID

[Company Logo][Company Name]

HOSPITALISATION INTIMATION AND CLAIM FORM

Company:: [Company Name]
Policy No.:: [Policy Number]
TPA:: [TPA Name]
TPA Intimation No.:: [Reference Number]
Date:: [Date]

Note: This internal form helps HR support your claim. The hospital's pre-authorisation request and the insurer's or TPA's claim form must also be completed where required.

Employee and Patient

Employee Name
Employee ID
Mobile Number
Patient Name
Relationship
E-card / Member ID

Admission Details

Admission Type: Planned / Emergency
Hospital Name and City
Network Hospital: Yes / No
Treating Doctor
Diagnosis / Proposed Procedure
Date of Admission
Expected Length of Stay (days)
Room Category Opted
Room Rent Eligibility as per Policy: ₹[Amount] per day

Form · Word

Hospitalization Claim Form

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Insurance Claim Assistance Form

Preview of the form

Employee and Policy

Nature of Assistance Needed

Claim Summary

Attachments

HR Action Log

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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