Employee Benefits Summary

EMPLOYEE BENEFITS SUMMARY

Personal Information

Position Information

Reporting Manager:

Start Date:    Base Salary (annual): $

Employment History (Most Recent)

Employment History (Prior)

Education

Professional References

Summary of Benefits

Eligibility: Employees scheduled to work at least hours per week are eligible for benefits after days of continuous employment.

Health Insurance

Plan Name:

Employer Contribution: $ per month. Employee Cost: $

Enroll    Decline coverage

Dental & Vision

Dental Plan:    Employee Cost: $

Vision Plan:    Employee Cost: $

Enroll in Dental    Enroll in Vision

Retirement Plan

Plan Type:    Employer Match:

Employee pre-tax contribution allowed up to:

Enroll    Opt out

Health Savings Account / Flexible Spending

HSA Eligible:   Employer Contribution: $

FSA Available:   Maximum employee election per year: $

Life Insurance & Disability

Basic Life Insurance Benefit: $ (Employer-paid)

Short-Term Disability:

Long-Term Disability:

Paid Time Off & Leaves

Vacation Accrual Rate: . Sick Leave:

Leave of Absence policies, including parental and medical leaves, follow company policy and applicable law. Continuation of health coverage during approved leave will be addressed by the benefits administrator.

Enrollment & Termination

New hires must complete benefit elections within days of eligibility. Coverage elected will be effective as of the plan effective date specified by the plan documents.

Upon termination of employment, continuation of coverage options and duration are governed by plan terms and applicable law. Employee share of premiums for continuation coverage may be required.

Benefits Administrator

Legal Disclosures

At-Will Employment: Employment with the company is at-will. Either the employee or the company may terminate the employment relationship at any time, with or without cause or notice, except as may be provided in a written agreement signed by an authorized company representative.

Equal Employment Opportunity: The company provides equal employment opportunity to all employees and applicants without regard to characteristics protected by applicable law. Benefit eligibility and administration will be applied without unlawful discrimination.

Authorization & Certifications

I certify that the information provided on this form, and any attachments, is true and complete to the best of my knowledge. I understand that intentional misrepresentation may result in denial of benefits and/or disciplinary action up to and including termination.

By checking the box below I authorize the company to contact prior employers and references provided for the purpose of verifying employment history and qualifications relevant to benefits eligibility and administration:

I authorize contact with previous employers and references

I also authorize the company to obtain consumer reports, criminal background checks, and other investigative information as permitted by law for purposes related to benefits administration and my employment. I understand that such reports may be obtained periodically during my employment, to the extent permitted by law.

I authorize background and investigative checks as described above

Additional Notes

Applicant Certification

I certify under penalty of perjury that the statements made on this form are true and accurate. I acknowledge receipt of this Employee Benefits Summary and understand that the summary is intended only as a general description of the benefits available and is not a guarantee of coverage. Actual benefits are governed by the terms of the plan documents and insurance contracts.

Employee acknowledgement: I have received and read the Employee Benefits Summary and understand my rights and options.

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