Enrollment Form

Effective Date of Enrollment/Cancellation/Change *

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Hire *

MM

DD

YYYY

Plans Affected *

Please check all that apply and be sure to complete each applicable section.

Medical - Section 1

Supplemental Medical Expense - GAP - Section 2

Dental - Section 3

Vision - Section 4

Life Insurance - Section 5

Long Term Disability - Section 5

Short Term Disability - Section 5

Section 125/Health FSA/Dependent Care Acct - Section 6

Who is enrolling in Medical?

If Child(ren) is selected, please list the number of children below.

Employee

Spouse

Child(ren)

WAIVER

I do not wish to enroll in medical benefits. I understand I may not be able to enroll until the next open Enrollment or unless I experience a qualifying event and notify my employer within 30 days of the qualifying event date.

I Acknowledge

Who is enrolling in Supplemental Medical Expense - GAP?

If Child(ren) is selected, please list the number of children below.

Employee

Spouse

Child(ren)

WAIVER

I do not wish to enroll in Supplemental Medical Expense benefits. I understand I may not be able to enroll until the next open Enrollment or unless I experience a qualifying event and notify my employer within 30 days of the qualifying event date.

I Acknowledge

Who is enrolling in Dental?

If Child(ren) is selected, please list the number of children below.

Employee

Spouse

Child(ren)

WAIVER

I do not wish to enroll in Dental benefits. I understand I may not be able to enroll until the next open Enrollment or unless I experience a qualifying event and notify my employer within 30 days of the qualifying event date.

I Acknowledge

Who is enrolling Vision?

If Child(ren) is selected, please list the number of children below.

Employee

Spouse

Child(ren)

WAIVER

I do not wish to enroll in Vision benefits. I understand I may not be able to enroll until the next open Enrollment or unless I experience a qualifying event and notify my employer within 30 days of the qualifying event date.

I Acknowledge

Short Term Disability

Long Term Disability

Employer Paid Life/AD&D Coverage. (If marked yes, please select from the following three options.)

Employee Voluntary Life/ADD

YES

Spouse/Domestic Partner Voluntary Life/ADD

YES

Child Children Voluntary Life/ADD

YES

Designate Your Primary Beneficiary (1/2)

First Name

Last Name

Designate Your Primary Beneficiary (2/2 - Optional)

First Name

Last Name

Designate Your Contingent Beneficiary (1/2)

First Name

Last Name

Designate Your Contingent Beneficiary (2/2- Optional)

First Name

Last Name

I authorize payroll deductions from my earnings for any contributions I am making. I understand any contributions not used for eligible expenses incurred during the plan year will be forfeited in accordance with current plan provisions. I further understand Section 125 Flexible Benefit Plan deductions will be in effect for the plan year and cannot be revoked unless I experience a qualifying event as defined in the plan document

I Acknowledge

Spouse

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 1

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 2

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 3

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 4

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 5

First Name

Last Name

Date of Birth

MM

DD

YYYY

DATE

MM

DD

YYYY