Employee Health Insurance Enrollment

EMPLOYEE HEALTH INSURANCE ENROLLMENT

Use this form to enroll in or change employer-sponsored health insurance benefits. Complete all sections applicable to you. Incomplete or unsigned forms may delay processing. By signing this form, the employee certifies the accuracy of the information provided and authorizes required payroll deductions.

Personal Information

Employment / Position Information

Requested coverage effective date:

Plan Selection (select all that apply)

Medical - Employee Only
Medical - Employee + Spouse
Medical - Family
Dental
Vision
Basic Life / AD&D
Dependent Life

Other Coverage

Is any dependent or the employee currently covered under another employer-sponsored health plan? Yes No

Premium Payment / Payroll Deduction Authorization

I authorize my employer to deduct from my earnings the required portion of premiums for the elected coverage. I understand that premium amounts may change and that deductions are subject to payroll schedules and applicable state and federal wage withholding laws. I understand that failure to pay required employee contributions may result in termination of coverage.

Premium payments for employer-sponsored health benefits will be made on a pre-tax basis unless the employee elects otherwise. Employee elects after-tax deductions: Yes

HIPAA & Privacy / Release of Information

By enrolling, I authorize the plan administrator and insurer to use and disclose protected health information as necessary to administer benefits. I authorize the release of enrollment and coverage information to the employer, insurer, and their representatives for enrollment, billing, and eligibility verification purposes.

I authorize any health plan, physician, hospital or other medically related facility to furnish to the plan administrator, insurer, or their designees any information regarding my or my dependents' medical history, treatment or benefits to the extent necessary to determine eligibility or process claims.

Legal Disclosures

At-Will Employment: Nothing contained in this enrollment form alters the employment relationship. Employment remains at-will and may be terminated by either the employer or employee at any time, with or without cause, unless otherwise provided in a separate written agreement signed by an authorized company representative.

Equal Opportunity Statement: The employer provides benefits without regard to race, color, religion, sex, national origin, age, disability, or any other protected characteristic as required by applicable law.

Employee Certification and Authorizations

I certify that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that intentionally providing false or misleading information may subject me to disciplinary action, rescission of coverage, reversal of claims, or other legal remedies. I authorize the employer to verify any information provided herein and to obtain any records necessary to process this enrollment.

By checking below I acknowledge and consent to the foregoing statements: I consent

Employment History (Most Recent)

Employer 1 - Company Name:

Employer 2 - Company Name:

Education

Professional References

Acknowledgment of Rights and Obligations

I understand that eligibility for coverage is governed by the terms of the plan documents, insurance contracts, and applicable law. I acknowledge that the employer may require documentation to substantiate dependent eligibility and that coverage for dependents may be terminated retroactively if eligibility cannot be verified. I understand that I must notify the employer of any changes in family status that affect coverage within the timeframe specified by plan rules.

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