Employee Benefits Plan

EMPLOYEE BENEFITS PLAN

Plan Identification

Plan Name:

Plan Effective Date:

Personal Information (Employee)

Position Information

Salary:

Employment Status: Full-time Part-time Temporary/Seasonal

Employment History (Most Recent)

Education

Graduation Date:

References (Professional)

Benefits Provided & Election

The Employer maintains the following benefit programs subject to plan terms and applicable insurance contracts. The employee elects coverage by checking the applicable boxes below and completing contribution information.

Medical Insurance Plan Option:

Dental Insurance Coverage Level:

Vision Insurance

Employer‑Paid Life Insurance Beneficiary:

Short‑Term Disability Long‑Term Disability

Retirement Plan (401(k) or similar) Employee Contribution: Employer Match:

Flexible Spending Account (FSA) Annual Election:

Dependent Coverage

Employee wishes to enroll dependents: Yes No

Eligibility, Enrollment and Changes

Eligibility: Employees classified as eligible per plan rules may enroll within the initial enrollment period or during a permitted special enrollment event. Enrollment elections are effective as provided in the plan document and summary plan description.

Changes in Elections: Changes are permitted only upon qualifying life events or during open enrollment. Documentation of qualifying events may be required by the Plan Administrator.

Claims, Appeals and Administration

Claims Procedures: Benefits subject to insurance contracts are governed by the claims and appeals procedures set forth in the applicable insurance policy and SPD. The Plan Administrator retains discretionary authority to interpret plan terms and to determine eligibility and benefit entitlement.

Plan Administrator: The Plan Administrator is responsible for plan governance, interpretation, claims oversight, and fiduciary duties to the extent required by law. Contact information provided above is the official administrative contact for benefit claims and inquiries.

Funding, Amendments and Termination

Funding: Employer contributions are subject to payroll deductions and may be insured or self‑funded. Specific funding arrangements for each benefit are described in the plan documents and insurance contracts.

Amendments and Termination: The Employer reserves the right to amend, modify or terminate the Plan in whole or in part at any time, subject to the terms of applicable contracts and law. No amendment or termination shall retroactively revoke benefits already paid in accordance with plan terms and applicable insurance contracts.

Legal Disclosures

At‑Will Employment: Nothing in this Benefits Plan or any related document creates an employment contract or guarantees employment for any specific term. Employment remains at will, meaning either the Employer or the Employee may terminate the employment relationship at any time, with or without cause or notice, unless otherwise provided by a separate written agreement.

Equal Employment Opportunity: The Employer provides benefits without regard to race, color, religion, sex, national origin, age, disability, or any other protected characteristic as defined by applicable law. Eligibility and benefit determinations will be applied in accordance with nondiscrimination requirements.

ERISA Notice: To the extent this Plan constitutes an employee welfare benefit plan subject to the Employee Retirement Income Security Act (ERISA), the Employer will administer the Plan in compliance with ERISA requirements. Certain benefits provided through insured group contracts may be governed by the terms of those contracts.

Applicant Certification and Authorizations

I certify that all information provided in this Enrollment and Plan Acknowledgement is complete and accurate to the best of my knowledge. I understand that knowingly providing false information may be grounds for denial of benefits or disciplinary action, up to and including termination.

Authorization to Obtain Information: I authorize the Employer, the Plan Administrator and their agents to verify information provided on this form and to contact prior employers, references, insurers, and other organizations for purposes of verifying eligibility, employment history, and benefit claims. I further authorize the release of necessary information to insurers or third‑party administrators to process claims and administer benefits.

Background and Benefits Eligibility Checks: I consent to a background check and verification of prior employment as necessary for benefits eligibility verification.

Acknowledgement and Enrollment Election

By signing below, I acknowledge receipt of the Plan Summary (where applicable), understand the terms and conditions of the Employee Benefits Plan as stated in this document, and elect the benefits indicated above. I authorize required payroll deductions associated with elected benefits and acknowledge that elections may be subject to plan rules and carrier eligibility.

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