Employee Benefits Package

EMPLOYEE BENEFITS PACKAGE

Employer Name:    Effective Date of Package:

Personal Information

Position Information

Full-time    Part-time    Temporary    Exempt    Non-exempt

Benefits Elections

Medical coverage (choose one or waive):

Medical PPO plan    Medical HMO plan    High-Deductible HSA-eligible plan    Waive medical coverage

Dental coverage:

Standard dental plan    Enhanced dental plan    Waive dental coverage

Vision coverage:

Basic vision plan    Enhanced vision plan    Waive vision coverage

Company-paid basic life insurance (amount as plan document)    Enroll in supplemental life insurance    Supplemental amount:

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

Retirement Plan

I elect to participate in the employer retirement plan: Enroll    Employee contribution:    Employer match acknowledgement: By enrolling I acknowledge the plan's matching provisions as set forth in plan documents.

Beneficiary Designation

Primary beneficiary 1 — Name: Relationship: Percent:

Contingent beneficiary 1 — Name: Relationship: Percent:

Dependent Information

Enrollment Acknowledgements and Notices

I acknowledge that the benefits described on this form are subject to the terms, conditions, and eligibility provisions of the official plan documents, insurance contracts and summary plan descriptions. In the event of any inconsistency, the controlling plan documents, insurance contracts and summary plan descriptions will govern. The employer reserves the right to amend, modify or terminate any plan or benefit, in whole or in part, at any time, subject to the terms of the governing plan documents and applicable law.

I understand that pretax elections for HSA, FSA and retirement contributions are irrevocable for the plan year unless allowed by law or the plan document. I understand that certain benefits may be subject to continuation rights after separation from employment under applicable continuation laws.

Legal Disclosures

At-Will Employment: Nothing in this document shall be construed to alter the at-will nature of employment when applicable. Either the employee or the employer may terminate the employment relationship at any time, with or without cause or notice, unless otherwise provided in a separate written agreement signed by an authorized representative of the employer.

Equal Employment Opportunity: The employer maintains an equal opportunity policy. Eligibility for benefits will be applied without regard to race, color, religion, sex, national origin, age, disability or other protected characteristic, except where a bona fide occupational qualification or applicable law provides otherwise.

Applicant Certification and Authorizations

I certify that all information provided on this form and any attachments is true, complete and correct to the best of my knowledge. I understand that knowingly providing false information may result in denial of benefits or disciplinary action up to and including termination of employment.

I authorize the employer and its agents to contact prior employers, insurance carriers, and other entities as necessary to verify information relevant to benefits eligibility and coverage. I authorize background checks and verification checks as permitted by law and required by plan administrators, contingent upon my prior written consent where required by law.

I acknowledge that I have received a copy of the summary plan descriptions and/or benefit summaries if provided, and that enrollment is subject to eligibility verification and any applicable waiting periods described in plan documents.

Employment History

Education

Professional References

Additional Authorizations

Background check authorization: I authorize the employer and its agents to obtain consumer and investigative consumer reports for employment-related purposes where permitted by law.

Payroll withholding for elected benefits is authorized: I authorize payroll deduction for employee contributions toward elected benefits as required by plan documents.

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