Employee Benefits Acknowledgement

EMPLOYEE BENEFITS ACKNOWLEDGEMENT

Personal Information

Position Information

Start Date:

Benefits Acknowledgement

I acknowledge that I have been provided information regarding the benefits program(s) available to eligible employees, including but not limited to health insurance, dental, vision, life insurance, disability coverage, retirement plan, and flexible spending accounts. I understand that plan terms, eligibility requirements, contribution amounts, and enrollment periods are governed by the applicable plan documents and summary plan descriptions.

I understand that eligibility for benefits may be subject to waiting periods, employment classification, and required contributions. I further acknowledge that the employer retains the right to amend, modify, suspend, or terminate any benefit plan at its discretion, to the extent permitted by the plan documents and applicable law.

By initialing the boxes below I confirm receipt of the following documents and confirm that I understand the enrollment deadlines and employee contribution obligations:

Health Plan Summary (Summary of Benefits and Coverage)

Dental Plan Summary

Vision Plan Summary

Retirement Plan Summary / 401(k) Notice

Flexible Spending / HSA Information

COBRA Continuation Rights Notice (where applicable)

Enrollment & Contributions

I understand that I must complete the required enrollment forms within the time frames specified by the employer to secure benefits coverage. I agree to authorize any payroll deductions required for elected benefit contributions at the levels elected at enrollment. I understand that changes to elections are generally limited to annual open enrollment or qualified life events as defined by the plan.

Employment History

Employer 1

From: To:

Employer 2

From: To:

Education

Graduation Date:

References

Reference 1

Reference 2

Reference 3

Legal Notices & Disclosures

At-Will Employment: I understand that my employment relationship with the employer is at-will unless otherwise expressly provided in a written agreement signed by an authorized representative of the employer. Either the employer or I may terminate the employment relationship at any time, with or without cause or advance notice, subject to applicable law.

Equal Opportunity: The employer is an equal opportunity employer. Employment decisions are based on business needs, job requirements and individual qualifications, without regard to race, color, religion, sex, national origin, age, disability, veteran status, genetic information, or other protected status as provided by law.

Plan Documents Control: I acknowledge that the official plan documents, insurance contracts, and summary plan descriptions govern the operation of each benefit. If there is any conflict between this acknowledgement and the plan documents, the terms of the plan documents will prevail.

COBRA and Continuation: Where applicable under law, continuation coverage may be available upon qualifying events. I understand I will receive notices describing my rights if COBRA or other continuation coverage applies.

Authorizations & Certifications

Background and References: I authorize the employer and its agents to contact prior employers, references, and educational institutions to verify information provided herein and to obtain any additional information necessary to evaluate my eligibility for employment and benefits. I authorize those parties to release information to the employer. I further authorize the employer to conduct background checks and drug screening where permitted by law as a condition of enrollment in certain benefit programs.

Privacy and Use of Information: I understand that personal information provided for benefit enrollment will be used by the employer and plan administrators for enrollment, eligibility determination, administration of benefits, and other activities permitted by law and the plan documents.

Authorization: I authorize contact with prior employers and references for verification purposes.

I authorize the employer to obtain background check information and screenings as permitted by law.

Employee Certification

I certify that all information provided on this form is true and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation may result in denial of benefits, disciplinary action, or termination of employment. I acknowledge that I have received and reviewed the benefit summaries indicated above and that I understand my responsibilities with respect to enrollment and contributions.

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