HR Insurance Checklist

HR INSURANCE CHECKLIST

Personal Information

Position Information

Full-Time    Part-Time    Temporary / Seasonal    Contract

Employment History (Most Recent First)

Education

References (Professional)

Insurance Enrollment Checklist

Complete each line to confirm HR actions and employee elections. HR will retain copies of documentation listed below and will enter elections into the carrier enrollment system where applicable.

Health Insurance

Eligible for health insurance:    Enrolled in health plan:    Plan name: Effective date:

Employee contribution (per pay): Waiver signed:    If waiving, reason:

Dental & Vision

Dental enrolled:    Plan:

Vision enrolled:    Plan:

Life & Disability

Employer-paid life insurance provided:    Coverage amount:

Beneficiary name: Relationship:

Voluntary life enrolled:    Short-term disability enrolled:    Long-term disability enrolled:

Flexible Spending / HSA

HSA elected:    Annual election:

FSA elected:    Annual election:

COBRA / Continuation

Employee informed of COBRA rights:    Date notified:

Workers' Compensation

Workers' compensation coverage explained:    Employee provided incident reporting procedure:

Documentation Collected

Government ID copied:    Date received:

Social Security verification:    Date verified:

Dependent eligibility documentation provided:    Type:

Other documentation:

Legal Disclosures

At-Will Employment: Employee acknowledges that employment, if any, is at-will and may be terminated by either party at any time with or without cause, subject only to a written agreement signed by an authorized representative of the company that expressly modifies this at-will relationship.

Equal Opportunity: The employer provides equal employment opportunity to all employees and applicants without regard to protected characteristics. Enrollment in benefit plans is administered consistent with nondiscrimination requirements applicable to those plans.

Privacy and Use: Employee authorizes the employer and its benefit administrators to collect, use and disclose necessary personal information for enrollment, eligibility determination, claims administration and regulatory reporting. Such information will be treated as confidential and disclosed only to insurers, third-party administrators and others with a legitimate need to administer benefits.

Authorization & Certification

By signing below, I certify that the information I have provided on this checklist is true, complete and accurate to the best of my knowledge. I understand that any false statement, omission or misrepresentation may be grounds for denial of benefits or termination of employment. I authorize the employer and its agents to contact previous employers, insurers, and other sources as necessary to verify enrollment history, coverage and other information relevant to eligibility and premium determinations.

I understand that plan eligibility, effective dates and coverage levels are governed by the applicable plan documents and insurance contracts, and that my election(s) are subject to the plans' terms, carrier approval, and applicable payroll deductions. I acknowledge responsibility for timely submission of required documentation to establish eligibility for dependents and beneficiaries.

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