Benefits Enrollment Form Template

This benefits enrollment form template has 3 pages and is a MS Word file type listed under our human resources documents.

Sample of our benefits enrollment form template:

[COMPANY NAME] BENEFITS ENROLLMENT FORM EMPLOYEE INFORMATION Employee Name: __________________________ Employee ID: __________________________ Department: __________________________ Job Title: __________________________ Hire Date: __________________________ Contact Information: __________________________ ENROLLMENT DATE Effective Date: __________________________ BENEFITS SELECTION Please select the benefits you wish to enroll in: Health Insurance: [ ] Medical [ ] Dental [ ] Vision [ ] Family Coverage (if applicable) Retirement Plan: [ ] 401(k) [ ] Roth 401(k) Life and Disability Insurance: [ ] Basic Life Insurance [ ] Supplemental Life Insurance [ ] Short-Term Disability [ ] Long-Term Disability Flexible Spending Accounts (FSA): [ ] Health Care FSA [ ] Dependent Care FSA Other Benefits: [ ] Employee Assistance Program (EAP) [ ] Wellness Program [ ] Commuter Benefits [ ] Other (Specify): _________________________ BENEFICIARY DESIGNATION Life Insurance Beneficiary: Primary Beneficiary: __________________________ Contingent Beneficiary: __________________________ DEPENDENTS INFORMATION Please list the dependents you are enrolling in your Benefits Plan, if applicable. Dependent 1: