HR ACA Packet

HR ACA Packet

Personal Information

Position Information

Reporting Manager:

Employment Start Date:

Employment Status (select one): Full-Time Part-Time Temporary/Seasonal

ACA Coverage Election

Employer-sponsored coverage is made available consistent with applicable health care reform requirements. Select the options you wish to elect:

Medical Insurance Dental Insurance Vision Insurance

If you decline employer medical coverage, please indicate reason and initial to acknowledge you understand your rights under the plan and the potential for limited future enrollment rights.

Employee Initials to Acknowledge Waiver:

Dependent Information

List dependents to be covered under selected plans. Attach additional sheets if necessary.

Waiver and Acknowledgment

By signing below, I understand that by declining employer-provided medical coverage I may be subject to limited special enrollment opportunities and that the employer will rely upon this selection for payroll deductions and plan administration.

I acknowledge and accept the terms of waiving coverage when applicable.

HIPAA & Privacy Acknowledgement

I acknowledge receipt of the employer's health plan privacy practices and consent to the release of necessary protected health information to the extent required for treatment, enrollment, premium collection, and plan administration.

I acknowledge the HIPAA privacy and authorize the release of protected health information as described above.

Employment History (Most Recent)

Employment History (Previous)

Education

References (Professional)

Provide three professional references who can speak to your work performance and character.

Legal Disclosures

At-Will Employment: Employment with the employer is at-will. Either the employee or the employer may terminate the employment relationship at any time, with or without cause, and with or without advance notice, unless a separate written agreement signed by an authorized representative expressly provides otherwise.

I acknowledge and understand the At-Will Employment statement above.

Equal Employment Opportunity: The employer is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, veteran status, or other protected characteristics under applicable law.

I acknowledge the Equal Employment Opportunity statement above.

Applicant Certification & Authorization

I certify that all information supplied on this HR ACA Packet and any attachments is true, complete and correct to the best of my knowledge. I understand that any materially false statement, omission, or misrepresentation may result in denial of benefits, disciplinary action, or termination of employment.

I authorize the employer, its agents, and its designated third-party administrators to contact former employers, educational institutions, references, and other sources to verify the information provided. I further authorize the release of information necessary to determine eligibility for benefits and to administer the employer's benefit plans, including background checks where permitted by law.

I authorize contact with previous employers, education providers and references and consent to background and eligibility verification as permitted by law.

Acknowledgment (Sign Below)

By signing below I certify the truthfulness of the information provided, accept the acknowledgements selected above, and authorize the employer to process enrollments, deductions, and verifications in accordance with plan and legal requirements.

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