EMPLOYEE BENEFITS ENROLLMENT FORM
CONFIDENTIAL INFORMATION
Plan Year: [YEAR]
I. EMPLOYEE PERSONAL INFORMATION
Full Legal Name: _______________________________ Employee ID: _________________
(Last, First, Middle Initial)
Social Security Number: _________________________ Date of Birth: ________________
(MM/DD/YYYY)
Home Address: ___________________________________________________________________
(Street Address) (Apt/Unit #)
(City) (State) (ZIP Code)
Contact Information:
- Primary Phone: ________________________ ☐ Mobile ☐ Home ☐ Work
- Secondary Phone: ______________________ ☐ Mobile ☐ Home ☐ Work
- Email Address: _____________________________________________________________
Employment Information:
- Date of Hire: __________________ Effective Date of Benefits: __________________
- Employment Status: ☐ Full-Time ☐ Part-Time ☐ Other: _________________________
- Department/Division: ________________________________________________________
- Job Title: _________________________________________________________________
II. DEPENDENT INFORMATION
Complete this section for all eligible dependents you wish to enroll in any benefit plan. Documentation of dependent eligibility may be required.
Spouse/Domestic Partner Information:
☐ Spouse ☐ Domestic Partner ☐ Not Applicable
Full Legal Name: _______________________________________________________________
(Last, First, Middle Initial)
Social Security Number: _________________________ Date of Birth: ________________
(MM/DD/YYYY)
Dependent Children Information:
List all eligible dependent children under age 26 (or older if disabled and dependent on you for support)
Dependent 1:
- Full Legal Name: ___________________________________________________________
(Last, First, Middle Initial)
- Social Security Number: _____________________ Date of Birth: ________________
- Relationship: ☐ Son ☐ Daughter ☐ Stepchild ☐ Other: _________________________
- Is this dependent disabled? ☐ Yes ☐ No
Dependent 2:
- Full Legal Name: ___________________________________________________________
(Last, First, Middle Initial)
- Social Security Number: _____________________ Date of Birth: ________________
- Relationship: ☐ Son ☐ Daughter ☐ Stepchild ☐ Other: _________________________
- Is this dependent disabled? ☐ Yes ☐ No
Dependent 3:
- Full Legal Name: ___________________________________________________________
(Last, First, Middle Initial)
- Social Security Number: _____________________ Date of Birth: ________________
- Relationship: ☐ Son ☐ Daughter ☐ Stepchild ☐ Other: _________________________
- Is this dependent disabled? ☐ Yes ☐ No
If you have additional dependents, please attach a separate sheet with their information.
III. HEALTH INSURANCE ELECTIONS
A. MEDICAL PLAN OPTIONS
Please select one option below. Employee contribution amounts shown are per pay period on a pre-tax basis.
Plan Options:
☐ Plan A: Preferred Provider Organization (PPO)
- Coverage Level:
- ☐ Employee Only: $_________ per pay period
- ☐ Employee + Spouse/Domestic Partner: $_________ per pay period
- ☐ Employee + Child(ren): $_________ per pay period
- ☐ Family: $_________ per pay period
- Annual Deductible: $________ Individual / $________ Family
- Co-Insurance: ____% after deductible
- Office Visit Co-Pay: $________ Primary Care / $________ Specialist
- Prescription Drug Co-Pays: $_____ Generic / $_____ Preferred Brand / $_____ Non-Preferred Brand
☐ Plan B: Health Maintenance Organization (HMO)
- Coverage Level:
- ☐ Employee Only: $_________ per pay period
- ☐ Employee + Spouse/Domestic Partner: $_________ per pay period
- ☐ Employee + Child(ren): $_________ per pay period
- ☐ Family: $_________ per pay period
- Annual Deductible: $________ Individual / $________ Family
- Co-Insurance: ____% after deductible
- Office Visit Co-Pay: $________ Primary Care / $________ Specialist
- Prescription Drug Co-Pays: $_____ Generic / $_____ Preferred Brand / $_____ Non-Preferred Brand
☐ Plan C: High Deductible Health Plan (HDHP) with HSA
- Coverage Level:
- ☐ Employee Only: $_________ per pay period
- ☐ Employee + Spouse/Domestic Partner: $_________ per pay period
- ☐ Employee + Child(ren): $_________ per pay period
- ☐ Family: $_________ per pay period
- Annual Deductible: $________ Individual / $________ Family
- Co-Insurance: ____% after deductible
- Prescription Drugs: Subject to deductible and co-insurance
- Employer HSA Contribution: $________ annually
☐ Waive Medical Coverage
- I understand that by waiving coverage, I cannot enroll until the next open enrollment period unless I experience a qualifying life event.
- Reason for waiving: ☐ Covered under spouse's plan ☐ Covered under parent's plan ☐ Individual coverage ☐ Other: _________________
B. DENTAL PLAN OPTIONS
Please select one option below. Employee contribution amounts shown are per pay period on a pre-tax basis.
☐ Dental Plan A: Comprehensive Coverage
- Coverage Level:
- ☐ Employee Only: $_________ per pay period
- ☐ Employee + Spouse/Domestic Partner: $_________ per pay period
- ☐ Employee + Child(ren): $_________ per pay period
- ☐ Family: $_________ per pay period
- Annual Deductible: $________ Individual / $________ Family
- Annual Maximum Benefit: $________
- Preventive Services: Covered at _____%
- Basic Services: Covered at _____%
- Major Services: Covered at _____%
- Orthodontia: ☐ Covered ☐ Not Covered | Lifetime Maximum: $________
☐ Dental Plan B: Basic Coverage
- Coverage Level:
- ☐ Employee Only: $_________ per pay period
- ☐ Employee + Spouse/Domestic Partner: $_________ per pay period
- ☐ Employee + Child(ren): $_________ per pay period
- ☐ Family: $_________ per pay period
- Annual Deductible: $________ Individual / $________ Family
- Annual Maximum Benefit: $________
- Preventive Services: Covered at _____%
- Basic Services: Covered at _____%
- Major Services: Covered at _____%
- Orthodontia: ☐ Covered ☐ Not Covered | Lifetime Maximum: $________
☐ Waive Dental Coverage
C. VISION PLAN OPTIONS
Please select one option below. Employee contribution amounts shown are per pay period on a pre-tax basis.
☐ Vision Plan
- Coverage Level:
- ☐ Employee Only: $_________ per pay period
- ☐ Employee + Spouse/Domestic Partner: $_________ per pay period
- ☐ Employee + Child(ren): $_________ per pay period
- ☐ Family: $_________ per pay period
- Eye Exam: $________ co-pay, once every ____ months
- Lenses: $________ co-pay, once every ____ months
- Frames: $________ allowance, once every ____ months
- Contact Lenses (in lieu of glasses): $________ allowance, once every ____ months
☐ Waive Vision Coverage
D. HEALTH SAVINGS ACCOUNT (HSA)
Only available if you enroll in the High Deductible Health Plan (HDHP)
☐ I elect to contribute to the HSA
- My contribution per pay period: $_________ (pre-tax)
- Annual employer contribution: $_________
- Note: The combined employee and employer contributions cannot exceed the annual IRS limits of $_________ for individual coverage or $_________ for family coverage. Individuals age 55 or older may contribute an additional $1,000 annually.
☐ I decline to contribute to the HSA at this time
E. FLEXIBLE SPENDING ACCOUNTS (FSA)
Annual election amounts will be divided by the number of pay periods in the plan year.
☐ Healthcare FSA (Not available if you elect an HSA)
- Annual Election Amount: $_________ (pre-tax)
- Note: Maximum annual contribution is $_________ per plan year. Unused funds exceeding $_________ will be forfeited at the end of the plan year plus any applicable grace period.
☐ Dependent Care FSA
- Annual Election Amount: $_________ (pre-tax)
- Note: Maximum annual contribution is $5,000 per household per plan year ($2,500 if married filing separately). Unused funds will be forfeited at the end of the plan year plus any applicable grace period.
☐ Limited Purpose FSA (For dental and vision expenses only; available if you elect an HSA)
- Annual Election Amount: $_________ (pre-tax)
- Note: Maximum annual contribution is $_________ per plan year. Unused funds exceeding $_________ will be forfeited at the end of the plan year plus any applicable grace period.
☐ I decline to participate in any FSA options at this time
F. OTHER SUPPLEMENTAL HEALTH BENEFITS
☐ Hospital Indemnity Plan
- Coverage Level:
- ☐ Employee Only: $_________ per pay period
- ☐ Employee + Spouse/Domestic Partner: $_________ per pay period
- ☐ Employee + Child(ren): $_________ per pay period
- ☐ Family: $_________ per pay period
☐ Critical Illness Insurance
- Coverage Amount: $_________
- Cost: $_________ per pay period
- Covered Dependents: ☐ None ☐ Spouse/Domestic Partner ☐ Child(ren) ☐ Family
☐ Accident Insurance
- Coverage Level:
- ☐ Employee Only: $_________ per pay period
- ☐ Employee + Spouse/Domestic Partner: $_________ per pay period
- ☐ Employee + Child(ren): $_________ per pay period
- ☐ Family: $_________ per pay period
☐ Wellness Program Participation
- ☐ I elect to participate in the company wellness program
- ☐ I decline to participate in the company wellness program
IV. RETIREMENT BENEFITS
A. 401(K) OR OTHER RETIREMENT PLAN
☐ I elect to participate in the company retirement plan
- Pre-tax contribution: _____% of my eligible compensation per pay period
- Roth (after-tax) contribution: _____% of my eligible compensation per pay period
- Total contribution: _____% of my eligible compensation per pay period
- Note: The company matches _____% of the first _____% you contribute. Employer contributions vest according to the following schedule: _____________________________________
☐ I elect to automatically increase my contribution by _____% annually up to a maximum of _____% of my eligible compensation
☐ I decline to participate in the company retirement plan at this time
- I understand that I may be automatically enrolled at _____% of my eligible compensation after _____ days of employment unless I explicitly opt out.
B. INVESTMENT ELECTIONS
Please indicate how you would like your retirement plan contributions invested. Total must equal 100%.
- Fund A: _____%
- Fund B: _____%
- Fund C: _____%
- Fund D: _____%
- Fund E: _____%
- Target Date Fund (based on expected retirement year): _____%
- Other: _____%
☐ I elect the default investment option as determined by the plan
V. LIFE AND DISABILITY INSURANCE
A. BASIC LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE
Employer-paid benefit
- Coverage Amount: $_________ or _____ times annual salary (maximum $_________ )
- Note: This benefit is provided at no cost to you.
B. SUPPLEMENTAL LIFE INSURANCE
Employee-paid benefit
☐ I elect Supplemental Life Insurance
- Coverage Amount: $_________ or _____ times annual salary (maximum $_________ )
- Cost: $_________ per pay period
- Note: Evidence of insurability may be required for coverage amounts over $_________ .
☐ I decline Supplemental Life Insurance
C. DEPENDENT LIFE INSURANCE
Employee-paid benefit
☐ I elect Spouse/Domestic Partner Life Insurance
- Coverage Amount: $_________
- Cost: $_________ per pay period
- Note: Evidence of insurability may be required for coverage amounts over $_________ .
☐ I elect Child(ren) Life Insurance
- Coverage Amount: $_________ per child
- Cost: $_________ per pay period (covers all eligible children)
☐ I decline Dependent Life Insurance
D. SHORT-TERM DISABILITY INSURANCE
☐ I elect Short-Term Disability Insurance
- Benefit: % of weekly earnings up to $____ per week
- Elimination Period: _____ days for accident / _____ days for illness
- Benefit Duration: Up to _____ weeks
- Cost: $_________ per pay period
☐ I decline Short-Term Disability Insurance
- ☐ Employer-paid benefit (if applicable)
E. LONG-TERM DISABILITY INSURANCE
☐ I elect Long-Term Disability Insurance
- Benefit: % of monthly earnings up to $____ per month
- Elimination Period: _____ days
- Benefit Duration: Up to _____ years or to age _____
- Cost: $_________ per pay period
☐ I decline Long-Term Disability Insurance
- ☐ Employer-paid benefit (if applicable)
F. BENEFICIARY DESIGNATIONS
For Life Insurance and Retirement Plan benefits
Primary Beneficiary(ies):
-
Full Name: _______________________________________________________________
Relationship: ________________________ Date of Birth: ___________________
Social Security Number: __________________ Allocation Percentage: ______%
-
Full Name: _______________________________________________________________
Relationship: ________________________ Date of Birth: ___________________
Social Security Number: __________________ Allocation Percentage: ______%
Contingent Beneficiary(ies):
-
Full Name: _______________________________________________________________
Relationship: ________________________ Date of Birth: ___________________
Social Security Number: __________________ Allocation Percentage: ______%
-
Full Name: _______________________________________________________________
Relationship: ________________________ Date of Birth: ___________________
Social Security Number: __________________ Allocation Percentage: ______%
Note: Total allocation percentages must equal 100% for primary beneficiaries and 100% for contingent beneficiaries.
VI. ADDITIONAL BENEFITS
A. COMMUTER BENEFITS
Pre-tax benefit for qualified transit and parking expenses
☐ Transit Account
- Monthly Election Amount: $_________ (pre-tax)
- Note: Maximum monthly contribution is $_________ per month.
☐ Parking Account
- Monthly Election Amount: $_________ (pre-tax)
- Note: Maximum monthly contribution is $_________ per month.
☐ I decline Commuter Benefits
B. EMPLOYEE ASSISTANCE PROGRAM (EAP)
Employer-paid benefit
- Services Include: Confidential counseling, work-life resources, legal consultation, financial consultation, and referral services
- Coverage: _____ counseling sessions per issue per year for employee and eligible household members
- Note: This benefit is provided at no cost to you.
C. TUITION REIMBURSEMENT
☐ I acknowledge the availability of the Tuition Reimbursement Program
- Annual Maximum Reimbursement: $_________ per calendar year
- Eligible Expenses: Tuition, required fees, and required textbooks for approved courses
- Reimbursement Rate: _____% for grade A, _____% for grade B, _____% for grade C
- Note: Courses must be pre-approved and related to your current position or a reasonable career path within the company. Reimbursement is subject to continued employment for _____ months following course completion.
D. VOLUNTARY BENEFITS
Employee-paid benefits
☐ Legal Plan
- Cost: $_________ per pay period
- Coverage: Employee and eligible dependents
☐ Pet Insurance
- Cost: $_________ per pay period
- Coverage Level: ☐ Basic ☐ Enhanced ☐ Premium
☐ Identity Theft Protection
- Coverage Level: ☐ Employee Only: $_________ per pay period
☐ Family: $_________ per pay period
☐ Other Voluntary Benefits:
- ☐ _______________: $ per pay period
- ☐ _______________: $ per pay period
☐ I decline all Voluntary Benefits
VII. COMPLIANCE AND DISCLOSURES
A. HIPAA PRIVACY NOTICE ACKNOWLEDGMENT
I acknowledge that I have received a copy of the Notice of Privacy Practices, which describes how my protected health information may be used and disclosed by the health plan and my rights regarding this information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices upon request.
☐ I acknowledge receipt of the HIPAA Privacy Notice
B. SUMMARY OF BENEFITS AND COVERAGE (SBC) ACKNOWLEDGMENT
I acknowledge that I have received the Summary of Benefits and Coverage (SBC) for each health plan option available to me, as required by the Affordable Care Act. I understand that the SBC provides important information about the health plan's benefits, cost-sharing provisions, coverage examples, and exclusions in a standardized format.
☐ I acknowledge receipt of the Summary of Benefits and Coverage (SBC)
C. SPECIAL ENROLLMENT RIGHTS NOTICE
I understand that if I decline enrollment in the health plan for myself or my dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my dependents in this plan if I or my dependents lose eligibility for that other coverage (or if the employer stops contributing toward my or my dependents' other coverage). However, I must request enrollment within 30 days after my or my dependents' other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my new dependents. However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
Furthermore, if I or my dependents lose eligibility for coverage under Medicaid or the Children's Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, I may be able to enroll myself and my dependents. However, I must request enrollment within 60 days of the loss of Medicaid/CHIP coverage or the determination of eligibility for premium assistance.
☐ I acknowledge receipt of the Special Enrollment Rights Notice
D. COBRA CONTINUATION COVERAGE NOTICE
I understand that under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), I and/or my covered dependents may have the right to temporarily continue health coverage at group rates if coverage would otherwise end due to certain qualifying events such as termination of employment, reduction in hours, divorce, death, or a child ceasing to be an eligible dependent. I understand that I or my covered dependents would be responsible for the full cost of coverage plus an administrative fee.
☐ I acknowledge receipt of the COBRA Continuation Coverage Notice
E. MEDICARE PART D NOTICE
I acknowledge that I have received information regarding whether the prescription drug coverage offered by the company's health plan(s) is creditable coverage under Medicare Part D rules. Creditable coverage means that the prescription drug coverage is expected to pay, on average, as much as the standard Medicare prescription drug coverage. This information is important because it may affect my decision whether to enroll in a Medicare prescription drug plan and whether I may pay a higher premium (a penalty) if I join a Medicare drug plan at a later date.
☐ I acknowledge receipt of the Medicare Part D Notice
F. CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) NOTICE
I acknowledge that I have received information about premium assistance that may be available under Medicaid or the Children's Health Insurance Program (CHIP) for coverage of my children. I understand that if my children are eligible for Medicaid or CHIP and I am eligible for health coverage from my employer, my state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs.
☐ I acknowledge receipt of the CHIP Notice
G. SECTION 125 (CAFETERIA PLAN) ELECTIONS
I understand that my elections for health, dental, vision, and flexible spending account benefits are made on a pre-tax basis under Section 125 of the Internal Revenue Code. I acknowledge that these elections are binding for the entire plan year unless I experience a qualifying life event as defined by IRS regulations (such as marriage, divorce, birth, adoption, death, change in employment status, etc.). I understand that any change in my benefit elections must be consistent with the qualifying event and must be requested within 30 days of the event.
☐ I acknowledge and understand the Section 125 (Cafeteria Plan) election rules
VIII. ADMINISTRATIVE ELEMENTS
A. EFFECTIVE DATES
I understand that for new employees, benefits will become effective on the following dates:
- Medical, Dental, and Vision Insurance: First day of the month following _____ days of employment
- Life and Disability Insurance: First day of the month following _____ days of employment
- 401(k) or Retirement Plan: Eligible to participate after _____ days of employment
- Flexible Spending Accounts: First day of the month following _____ days of employment
- Other Benefits: As specified in the plan documents
For current employees during open enrollment, all elected benefits will become effective on [EFFECTIVE DATE].
B. PAYROLL DEDUCTION AUTHORIZATION
I hereby authorize my employer to deduct from my paycheck the required contributions for the benefits I have elected. I understand that my contribution amounts may change if:
- The cost of benefits changes;
- I have a change in employment status that affects my eligibility or cost for benefits;
- I make changes to my benefit elections due to a qualifying life event; or
- I modify my elections during a future open enrollment period.
I understand that some deductions will be taken on a pre-tax basis where permitted by law, and others will be taken on an after-tax basis as required by applicable regulations.
☐ I authorize payroll deductions for my portion of the benefit costs as indicated in this form
C. WAIVER OF COVERAGE
For each benefit I have waived or declined, I understand that:
- I am under no obligation to enroll in any benefit plan offered by my employer;
- By waiving coverage, I (and my eligible dependents, if applicable) will not have coverage under the employer-sponsored plan;
- If I waive health insurance coverage, I may not be eligible for a premium tax credit for coverage purchased through a Health Insurance Marketplace;
- I cannot enroll in the waived benefits until the next open enrollment period unless I experience a qualifying life event; and
- Some benefits may require evidence of insurability if I choose to enroll at a later date.
☐ I acknowledge and understand the implications of waiving coverage for any benefits I have declined
D. QUALIFYING LIFE EVENT INFORMATION
I understand that I may make changes to my benefit elections during the plan year only if I experience a qualifying life event. Qualifying life events include, but are not limited to:
- Marriage, divorce, or legal separation
- Birth, adoption, or placement for adoption of a child
- Death of a spouse or dependent
- Change in employment status for me, my spouse, or dependent
- Gain or loss of other coverage for me, my spouse, or dependent
- Change in residence that affects benefit eligibility
- Entitlement to Medicare or Medicaid
I understand that I must notify Human Resources and submit required documentation within 30 days of the qualifying life event (60 days for certain CHIP/Medicaid events). I further understand that any benefit changes must be consistent with the qualifying event.
☐ I acknowledge and understand the qualifying life event rules
E. OPEN ENROLLMENT PERIOD INFORMATION
I understand that the annual open enrollment period typically occurs [TIMEFRAME] each year, with elections becoming effective on [EFFECTIVE DATE]. During open enrollment, I may:
- Enroll in or waive coverage for any benefit plan offered
- Add or remove dependents from coverage
- Change plan options within a benefit category
- Adjust contribution amounts for flexible spending accounts and health savings accounts
I understand that elections made during open enrollment are binding for the entire plan year unless I experience a qualifying life event.
☐ I acknowledge and understand the open enrollment period rules
F. CONTACT INFORMATION
For questions about benefits or to report qualifying life events, please contact:
Human Resources/Benefits Department:
- Phone: [PHONE NUMBER]
- Email: [EMAIL ADDRESS]
- Office Location: [LOCATION]
- Hours: [HOURS]
Insurance Carriers and Third-Party Administrators:
- Medical Plan: [CARRIER NAME] | Phone: [PHONE] | Website: [WEBSITE]
- Dental Plan: [CARRIER NAME] | Phone: [PHONE] | Website: [WEBSITE]
- Vision Plan: [CARRIER NAME] | Phone: [PHONE] | Website: [WEBSITE]
- Life/Disability: [CARRIER NAME] | Phone: [PHONE] | Website: [WEBSITE]
- 401(k)/Retirement: [ADMINISTRATOR] | Phone: [PHONE] | Website: [WEBSITE]
- FSA/HSA: [ADMINISTRATOR] | Phone: [PHONE] | Website: [WEBSITE]
- EAP: [PROVIDER] | Phone: [PHONE] | Website: [WEBSITE]
G. ELECTRONIC DELIVERY CONSENT
☐ I consent to receive benefits information and required notices electronically
- Email Address for Electronic Delivery: _____________________________________________
- I understand that I have the right to receive paper copies of all benefits information and required notices at no charge by contacting Human Resources.
- I understand that I may withdraw this consent at any time by providing written notice to Human Resources.
- I certify that I have access to the internet and the ability to view, save, and print PDF documents.
☐ I decline electronic delivery and prefer to receive benefits information and required notices in paper form
H. CONFIRMATION STATEMENT
I understand that after my enrollment is processed, I will receive a confirmation statement summarizing my benefit elections, covered dependents, and associated costs. I will review this statement carefully and notify Human Resources immediately of any discrepancies or errors.
IX. EMPLOYEE CERTIFICATION AND SIGNATURE
By signing below, I certify that:
- I have read and understand the benefit options available to me and the costs associated with each option.
- The information provided on this form is true and correct to the best of my knowledge.
- I understand that providing false information may result in disciplinary action up to and including termination of employment and may subject me to legal action.
- I authorize the release of information necessary to process my benefit elections and claims.
- I understand that this form does not guarantee coverage and that eligibility requirements must be met for each benefit.
- I have received all required notices and disclosures referenced in this form.
- I understand that my elections will remain in effect for the entire plan year unless I experience a qualifying life event that allows for a mid-year change.
- I authorize my employer to make the necessary payroll deductions for my portion of the benefit costs.
Employee Signature: __________________________________ Date: ________________
Print Name: _________________________________________________________________
FOR EMPLOYER USE ONLY
Received By: __________________________________ Date Received: ________________
Processed By: _________________________________ Date Processed: _______________
Effective Date of Coverage: ____________________
Notes/Comments:
