Employee Benefits Packet

EMPLOYEE BENEFITS PACKET

Personal Information

Position Information

Employment History (Most Recent)

Employment History (Previous Employer)

Education

References (Professional)

Benefit Elections

Elections made on this form are effective on the plan effective date designated by the employer and remain in effect for the applicable plan year unless changed during an employer-designated enrollment period or upon a qualifying life event as defined by plan documents. By selecting coverage below, I authorize payroll deductions necessary to fund my elections and confirm I will provide documentation to substantiate dependent eligibility upon request.

Employee Only    Employee + Spouse    Employee + Children    Family

Employee Only    Family

Enroll in vision coverage

Enroll in HSA    Contribution Amount:

Enroll in Flexible Spending Account (FSA)    Election Amount:

Basic Employer-Provided Life Insurance    Supplemental Life Insurance (employee-paid)

Dependents & Beneficiaries

I certify that any dependents listed are eligible under plan definitions. I understand that documentation (birth certificates, marriage certificates, court orders) may be required to confirm eligibility. I further designate beneficiaries for life and retirement benefits as below.

Disability, Retirement & Additional Coverages

Short-term and long-term disability coverage is provided in accordance with plan documents. Enrollment in retirement savings plans is governed by plan rules including eligibility, vesting and contribution limits.

Enroll in Short-Term Disability    Enroll in Long-Term Disability

Enroll in Retirement Plan (401k/403b)    Contribution (% of pay):

Legal Disclosures & Authorizations

At-Will Employment: I understand that my employment, if any, is at-will, which means either the employee or the employer may terminate the employment relationship at any time with or without cause or notice, unless otherwise agreed in a written contract signed by an authorized representative of the employer.

Equal Employment Opportunity: The employer provides equal employment opportunity and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, or any other characteristic protected by law. Benefit eligibility and administration will be applied in a nondiscriminatory manner in accordance with applicable law.

I authorize the employer and its agents to obtain information about my employment history, criminal background, and other information necessary to verify eligibility for employment and benefits. I release prior employers and other providers of information from liability for furnishing such information in good faith.

I acknowledge receipt of notice regarding continuation coverage (COBRA) rights and notice of privacy practices related to protected health information (HIPAA). I understand that continuation coverage and privacy protections are governed by plan documents and applicable law.

By signing below I authorize the employer to deduct from my wages the amounts necessary to pay for the benefit elections indicated on this form, including pre-tax elections where applicable. I understand that certain elections are irrevocable for the plan year except as permitted by plan rules for qualifying events.

Certification

I certify that all information provided on this form is true, accurate and complete to the best of my knowledge. I understand that providing false or misleading information may result in denial of benefits, recovery of paid benefits, disciplinary action up to and including termination, and other remedies available under law. I agree to notify the employer promptly of any changes that affect benefit eligibility.

Sign Now