A nominee change form lets an employee replace or add nominees for employer-linked benefits such as gratuity, group term life insurance and other dues payable on death. It records the new nominees, their share and witnesses, and notes where statutory forms must also be filed.
I hereby cancel my earlier nomination(s) for the benefits ticked below and nominate the following person(s).
Gratuity
Group term life insurance
Group personal accident insurance
Unpaid salary, leave encashment and other dues
Other: [Specify]
Nominee Name
Relationship
Date of Birth
Address
Share (%)
Guardian (if minor)
[Name]
[Relationship]
[DD/MM/YYYY]
[Address]
[%]
[Guardian Name / NA]
[Name]
[Relationship]
[DD/MM/YYYY]
[Address]
[%]
[Guardian Name / NA]
[Name]
[Relationship]
[DD/MM/YYYY]
[Address]
[%]
[Guardian Name / NA]
Note: For Provident Fund, I will file or update my e-nomination through the EPFO member portal using my UAN.
Privacy notice: [Company Name] collects the details on this page only for paying benefits and dues to your nominees. Access is limited to authorised HR staff, and the record will be kept for the duration of employment and until all dues are settled, plus the retention period, after which it will be securely deleted or destroyed. You may ask HR to see or correct your data, consistent with the Digital Personal Data Protection Act, 2023.
Employee [Employee Name] Date: [Date]
Witness 1 Name: [Name] Signature
Witness 2 Name: [Name] Signature
Acknowledgement
Received the above nomination on [Date] and filed in the personnel file of [Employee Name].
Reference to statutory forms such as PF e-nomination
Acknowledgement by HR with date
When to use it
After marriage, when the spouse becomes a nominee
After the death of an existing nominee
When an employee wants to change share percentages
When a minor nominee needs a guardian named
How to customise this template
1List every benefit your company offers that needs a nominee
2Add your insurer's policy number
3Note that PF nomination is filed online by the employee through the member portal
4Use the statutory gratuity nomination format where your rules require it
5Keep a copy in the sealed section of the personnel file
HR tips
Check that shares add up to exactly 100 per cent
Record nominee contact only as much as needed to pay dues
Remind employees that nominations do not settle inheritance disputes
Acknowledge receipt in writing so the employee knows it is on file
Statutory nominations for PF, gratuity and similar benefits may need prescribed forms. Use this form alongside them and confirm requirements with your legal or compliance adviser.
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Call-back done on registered mobile on [Date] by [Name]
Penny-drop / test credit successful (if used)
Updated in payroll from [Month YYYY]
Privacy notice: [Company Name] collects the details on this page only for crediting your salary and reimbursements. Access is limited to authorised HR staff, and the record will be kept for the duration of employment and the statutory retention period for payroll records, after which it will be securely deleted or destroyed. You may ask HR to see or correct your data, consistent with the Digital Personal Data Protection Act, 2023.