Benefits Enrollment Form

BENEFITS ENROLLMENT FORM Read the Benefits Summary before completing. Elections take effect on your benefits effective date. EMPLOYEE INFORMATION Name: [First Name] [Last Name] | Employee ID: [Number] Job Title: [Title] | Department: [Department] Hire Date: [Date] | Benefits Effective Date: [Date] Enrollment Type: ☐ New Hire ☐ Open Enrollment ☐ Qualifying Life Event If QLE, type: [Marriage / Divorce / Birth / Adoption / Death / Loss of Coverage / Other] SECTION A: MEDICAL INSURANCE ☐ I want to enroll. | ☐ I am declining. Reason: [Covered Elsewhere / Not Needed / Other] Plan: ☐ [Plan 1] ☐ [Plan 2] ☐ [Plan 3] Coverage: ☐ Employee Only ☐ Employee + Spouse ☐ Employee + Child(ren) ☐ Employee + Family Dependents: Name | Relationship | DOB | SSN/ID [Name] | [Relation] | [DOB] | [ID] [Name] | [Relation] | [DOB] | [ID] SECTION B: DENTAL — ☐ Enroll (Plan: [Name], Tier: [Tier]) ☐ Decline SECTION C: VISION — ☐ Enroll (Plan: [Name], Tier: [Tier]) ☐ Decline SECTION D: LIFE INSURANCE Basic (company): ☐ Enrolled (Amount: [Amt]) ☐ Decline Supplemental (employee-paid): ☐ Enroll (Amount: [Amt]) ☐ Decline Spouse: ☐ Enroll (Amount: [Amt]) ☐ Decline Child: ☐ Enroll (Amount: [Amt]) ☐ Decline Beneficiary: Primary: [Name], [Relation], [Allocation]% | Contingent: [Name], [Relation], [Allocation]% SECTION E: DISABILITY — STD: ☐ Enroll ☐ Decline | LTD: ☐ Enroll ☐ Decline SECTION F: RETIREMENT / PF ☐ Contribute to [Plan Name] — Amount: [Percentage]% or [Amount] per pay period ☐ Not contributing at this time Nominee: [Name], [Relation], [Allocation]% SECTION G: OTHER FSA Healthcare: ☐ Enroll — Annual: [Amount] ☐ Decline FSA Dependent Care: ☐ Enroll — Annual: [Amount] ☐ Decline HSA: ☐ Enroll — Annual: [Amount] ☐ Decline Commuter: ☐ Enroll — Transit: [Amt]/mo | Parking: [Amt]/mo ☐ Decline Voluntary: ☐ Critical Illness ☐ Accident ☐ Hospital Indemnity ☐ Pet ☐ Legal ☐ Other SECTION H: ACKNOWLEDGMENT I have read the Benefits Summary. My selections take effect on the date noted. Premiums will be deducted pre-tax where permitted. Changes only during open enrollment or qualifying life events. Signature: _______________________ Date: _______________________ FOR HR USE ONLY Processed: ☐ Yes — by [Name] on [Date] | Confirmation sent: ☐ Yes — on [Date] Payroll deductions configured: ☐ Yes — by [Name] on [Date]