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Mediclaim Declaration Form

A mediclaim declaration form is a signed statement in which an employee confirms their dependants, discloses relevant health information and states whether they opt in or out of the company group mediclaim. HR uses it as the record behind every addition, exclusion or premium deduction.

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[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

Name	Relationship	Date of Birth	Dependent on Me (Y/N)
[Dependant Name]	[Relationship]	[DD/MM/YYYY]	[Y/N]
[Dependant Name]	[Relationship]	[DD/MM/YYYY]	[Y/N]
[Dependant Name]	[Relationship]	[DD/MM/YYYY]	[Y/N]

D. Health Disclosure

Has any member been hospitalised in the last 3 years? Yes / No. If yes, details:
Is any member under ongoing treatment for a chronic condition? Yes / No. If yes, details:
Is any member currently pregnant? Yes / No
Other health insurance held (Insurer, Policy No., Sum Insured):

E. Deduction Authority

I authorise [Company Name] to deduct ₹[Amount] from my salary towards the employee share of premium for the voluntary cover selected above.

F. Declaration

I declare that the information provided is true to the best of my knowledge. I understand that incorrect or incomplete disclosure may lead the insurer to reject or reduce a claim, and that cover is subject to the policy terms. I will inform HR of any change during the policy year.

Employee
[Employee Name]
Date: [Date]

Received by HR
[HR Name]
Date: [Date]

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What this template includes

Clear opt-in or opt-out choice with consequences explained
Dependant confirmation list for the current policy year
Health disclosure questions answered yes or no
Details of any other health policy, useful for claim contribution
Salary deduction authority for voluntary premiums
Acknowledgement that non-disclosure may affect claims

When to use it

When an employee wants to opt out because they are covered under a spouse's employer policy
At annual renewal when the insurer asks for a fresh dependant declaration
When parental cover is voluntary and needs written consent for deduction
When an employee joins mid-policy and must confirm health status for the endorsement

How to customise this template

1Decide whether opt-out is allowed at all; many companies make base cover compulsory
2Insert the policy year and premium per member for voluntary cover
3Adjust the health questions to those your insurer or broker requires
4Add a re-entry rule, for example opt-outs may rejoin only at renewal

HR tips

Keep health questions minimal and relevant, and restrict access to the completed form
If an employee opts out, record the reason and the other policy number
Re-collect declarations every renewal rather than relying on old records
Explain in plain words that dependants not declared will not be covered

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Frequently asked questions

What is a mediclaim declaration?+

It is a signed statement confirming who you want covered under the company mediclaim, any health conditions you need to disclose and whether you agree to premium deductions.

Can I opt out of company mediclaim?+

Only if your company policy allows it. Where allowed, you typically sign an opt-out declaration and give details of your alternative cover.

Do I need to declare my personal health insurance?+

It is good practice. If you have more than one policy, insurers may ask about other cover during a claim.

All 50 employee benefits & insurance →

[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
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Employee Benefits Enrollment Form
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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

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Benefits Selection Form

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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)

Form · Word

Group Insurance Nomination Form

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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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Insurance Claim Assistance Form
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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
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Employee Insurance Correction Form
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Member Name (as currently on e-card)
Relationship
E-card / Member ID

Mediclaim Declaration Form

Preview of the form

A. Employee Particulars

B. Choice of Cover (tick one)

C. Dependants Declared for this Policy Year

D. Health Disclosure

E. Deduction Authority

F. Declaration

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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