Employee Health Benefits Acknowledgment

EMPLOYEE HEALTH BENEFITS ACKNOWLEDGMENT

Personal Information

Position Information

Start Date:    Annual Salary:

Employment History (Most Recent First)

Dates Employed: From   To

Dates Employed: From   To

Education

Graduation Date:

Professional References

Health Benefits Acknowledgment

I acknowledge that I have been provided with the employer's Summary Plan Description(s) and plan materials describing the health and welfare benefit plans offered by the employer. I understand that the plan documents, insurance policies, summary plan descriptions and insurance contracts constitute the definitive statements of the terms and conditions that govern coverage, and that this acknowledgment does not modify the terms of any plan.

I understand eligibility rules, waiting periods, and enrollment deadlines described in the plan materials. I understand that benefit elections made during an open enrollment period or an eligible change-in-status event are generally irrevocable for the plan year except as permitted by plan rules or applicable law.

I understand that participation in certain plans may require pre-tax payroll deductions and that the employer will withhold premiums, contributions, or repayment amounts from my pay as required by my elections and plan provisions. I consent to payroll deductions for my elected coverages to the extent permitted by plan rules.

I have been informed of my potential rights under continuation coverage (e.g., COBRA or similar state law), privacy protections under applicable privacy laws, and procedures for filing claims and appeals. I understand that the employer reserves the right to amend, modify or terminate any benefit plan at any time, subject to plan provisions and legal requirements.

Acknowledgment Items

I acknowledge receipt of the Summary Plan Description(s) and benefit enrollment materials.

I understand enrollment deadlines, effective dates, and conditions for coverage.

I authorize payroll deductions for benefit premiums and authorized contributions.

I acknowledge receipt of the employer's privacy practices notice applicable to health information.

Benefit Elections

I elect to enroll in the following plans (check all that apply):
Medical Insurance    Dental Insurance    Vision Insurance

Life Insurance    Short/Long-Term Disability    Flexible Spending Account (FSA)

Health Savings Account (HSA) — If checked, anticipated annual contribution:

I DECLINE to enroll in employer-sponsored coverage at this time:

Legal Disclosures

At-Will Employment: I acknowledge that my employment, if any, is on an at-will basis unless otherwise provided in a written agreement signed by an authorized representative of the employer. Nothing in this acknowledgment or in the benefit materials alters the at-will employment relationship.

Equal Opportunity: The employer provides equal employment opportunity and does not discriminate in benefit eligibility or administration on protected bases. Benefit eligibility and coverage determinations are made in accordance with plan terms and applicable law.

Plan Control: Benefit plans are maintained under written plan documents and insurance contracts which control the operation of the plans. This acknowledgment is not a plan document and does not create any contractual right to benefits beyond those provided in the controlling plan documents.

Applicant Certification & Authorization

I certify that the information I have provided on this form is true, complete, and correct to the best of my knowledge. I understand that falsification of information may result in disciplinary action, up to and including termination of employment and rescission of coverage.

I authorize the employer and its designated administrators and agents to contact prior employers, references and other entities to verify information necessary to establish eligibility for benefits and to conduct background checks as permitted by applicable law. I authorize release of employment-related information to the plan administrator, insurer, and their designees for purposes of administering benefits.

I understand that certain benefits and continuation rights may be subject to federal or state law (for example, continuation coverage and privacy protections) and that additional notices may be provided where required by law.

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