Employee Benefits Overview Form

EMPLOYEE BENEFITS OVERVIEW FORM

Personal Information

Position and Employment Data

Employment Status: Full Time Part Time Temporary/Contractor

Benefits Overview and Enrollment Intent

The following summaries describe the principal features of benefit programs offered by the employer. Actual coverage, eligibility, and claims are governed by the official plan documents, insurance contracts, and summary plan descriptions. Participation is subject to plan terms, waiting periods, and timely enrollment.

Health, Dental & Vision

Health Insurance: Medical plans include in-network and out-of-network benefits, deductibles, and co-insurance. Enrollment elections will become effective on the first day of coverage following the plan waiting period.

Enroll in Medical: Yes Decline

Dental Coverage: Enroll Decline

Vision Coverage: Enroll Decline

Life, Disability & Income Protection

Employer-provided basic life insurance and short-term/long-term disability plans are subject to policy terms and medical underwriting where applicable.

Basic Life Insurance: I elect employer basic life coverage: Yes Decline

Supplemental Life or Voluntary AD&D (employee or dependents): Elect Decline

Retirement & Flexible Spending

401(k) or Retirement Plan: Employees may be eligible to participate subject to plan rules, vesting, and employer match provisions.

Elect to participate in retirement plan: Yes No

Flexible Spending Account (FSA) — health and/or dependent care: Elect Decline

Dependents and Beneficiaries

Premiums, Payroll Deductions & COBRA

I acknowledge that premiums for elected benefits will be collected through payroll deductions in accordance with employer payroll practices. I understand COBRA or similar continuation coverage may be available upon qualifying events as required by applicable law.

I authorize payroll deduction for employee contributions: Yes

Employment History (most recent two employers)

Education

Graduation Date:

References (professional)

Legal Disclosures & Authorizations

At-Will Employment: Nothing in this benefits overview creates an express or implied contract guaranteeing employment for any specific duration. Employment remains at-will and may be terminated by either party at any time, with or without cause, to the extent permitted by law.

Equal Employment Opportunity: The employer provides equal opportunity in all employment practices without regard to protected characteristics and complies with applicable equal opportunity laws.

Plan Documents and Controlling Terms: All benefits described are subject to the terms and conditions of the official plan documents, insurance policies, contracts and summary plan descriptions. In the event of any inconsistency between this overview and the controlling plan documents, the plan documents govern.

Authorization to Obtain Information: By signing below, I authorize the employer and its authorized representatives to contact former employers, references, and any listed medical providers or insurers, and to obtain background checks, verification of employment, education, and other information necessary to administer benefits and verify eligibility. I understand additional authorizations may be required for certain medical or underwriting processes.

Consent to Electronic Delivery: I consent to receive notices, disclosures, and documents related to benefits electronically unless I revoke this consent in writing in accordance with employer procedures.

I hereby authorize the foregoing: I Agree

Applicant Certification

I certify that the information provided on this form is true, accurate and complete to the best of my knowledge. I understand that willful misrepresentation or omission of material facts may result in denial of benefits, disciplinary action, or termination of employment. I acknowledge that benefits are subject to eligibility, plan provisions, and applicable law.

By signing below I affirm that I have received and reviewed the benefit summaries provided, understand that complete plan documents govern rights and obligations, and authorize payroll deductions and information releases as indicated.

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