Employee Benefits Addendum

EMPLOYEE BENEFITS ADDENDUM

This Employee Benefits Addendum (the "Addendum") is made effective as of by and between the Employer and Employee identified below. This Addendum supplements and modifies the Employee's terms of employment solely with respect to employee benefit programs and does not alter any other terms of employment except as expressly stated.

Employee Information

Position Information

Employee start date:

Benefits Summary and Elections

The Employer maintains benefit programs that are governed by plan documents, insurance policies and summary plan descriptions. The specific terms, eligibility, coverage, limitations and claims procedures of each plan are controlled by those documents. The following selections record current enrollment elections, employer contribution levels, and any waivers executed by the Employee.

Medical Insurance

Enroll in medical plan    Waive medical coverage (employee acknowledges loss of employer contribution)

Dental and Vision

Enroll in dental    Waive dental

Enroll in vision    Waive vision

Life Insurance and Beneficiary Designation

Short-Term and Long-Term Disability

Enroll in short-term disability    Enroll in long-term disability

Retirement Plan

Flexible Spending / Health Savings Accounts

Elect FSA    Elect HSA

Paid Time Off (PTO)

Other Benefits and Programs

Enrollment and Payroll Authorization

By electing any employee-paid benefits above, the Employee authorizes payroll deduction of required employee contributions, pre-tax where permitted and after-tax only where necessary to effectuate plan design. The Employee acknowledges and agrees that the Employer may deduct from final wages any benefit overpayments or premiums required to correct an administrative error to the extent permitted by law.

Employee authorizes payroll deduction for elected benefits.

Eligibility, Amendment, and Termination of Benefits

Benefit eligibility is subject to plan eligibility rules and any waiting periods stated in plan documents. The Employer reserves the unilateral right to amend, suspend or terminate any benefit plan, program or carrier arrangement at any time, subject to applicable law. No verbal statement by any representative of the Employer modifies the written plan documents or this Addendum.

Designated Emergency Contact

Employment History

Provide two most recent employers.

Education

Graduation date:

References

Provide three professional references.

Legal Disclosures and Authorizations

At-Will Employment: The Employee acknowledges that employment is at-will unless governed by a separate written agreement signed by an authorized representative of the Employer. Nothing in this Addendum creates a contract guaranteeing employment for any fixed period.

Equal Opportunity: The Employer provides equal employment opportunities in accordance with applicable law and does not discriminate in benefit eligibility or administration on prohibited bases.

Background Checks and Employment References: The Employee authorizes the Employer to verify information provided in this Addendum and the Employee's employment application, including contacting prior employers and references, and to obtain background, criminal, motor vehicle and education checks where permitted by law. The Employee further certifies that information provided in this Addendum and associated forms is true and complete.

I consent to employer verification and background checks as described above.

Applicant / Employee Certification

I certify that all information provided in this Addendum is true and complete to the best of my knowledge. I understand that falsification or omission of material information may be grounds for denial of benefits, disciplinary action, or termination of employment. I acknowledge that benefit availability, contribution rates and eligibility are subject to change as described above and in plan documents.

The Employee agrees to notify the Employer promptly of any change in circumstances affecting eligibility for benefits, including changes in dependent status or address. The Employee further acknowledges receipt of any required enrollment materials and that benefits are administered in accordance with the controlling plan documents and insurance contracts.

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