Benefits Enrollment Questionnaire HR
Benefits Enrollment Questionnaire
This document is designed to collect essential information for your benefits enrollment process. Please complete the following sections to customize your employee benefits package for the upcoming period.
|
Section 1: Personal Information |
|
|
Full Name: |
Edward Nichols |
|
Employee ID: |
123456 |
|
Email Address: |
edwardnichols@email.com |
|
Date of Birth: |
01/15/2001 |
|
Social Security Number (SSN) |
123-45-6789 |
|
Address: |
21 E. Pin Oak Dr. Oakland Gardens, NY 11364 |
|
Section 2: Dependent Information |
|
|
Spouse's Full Name: |
Greta Nichols |
|
Spouse's Date of Birth: |
05/20/2005 |
|
Child 1 Full Name: |
Slater Nichols |
|
Child 1 Date of Birth: |
03/10/2030 |
|
Child 2 Full Name: |
Michael Nichols |
|
Child 2 Date of Birth: |
08/25/2032 |
|
Section 3: Current Benefit Elections |
|
|
Medical Plan: |
PPO Gold |
|
Dental Coverage: |
Comprehensive Dental |
|
Vision Insurance: |
Vision Plus |
|
Life Insurance: |
Basic Life Insurance |
|
Disability Insurance: |
Short-term Disability |
|
Retirement Plan Contributions: |
10% of Salary |
Please indicate your benefit selections for the upcoming benefits period.
|
Section 4: Benefit Selections |
|
|
Medical Plan: |
HMO Silver |
|
Dental Coverage: |
Dental Basic |
|
Vision Insurance: |
Vision Care |
|
Life Insurance: |
Enhanced Life Insurance |
|
Disability Insurance: |
Long-term Disability |
|
Retirement Plan Contributions: |
5% of Salary |
|
Section 5: Beneficiary Information |
|
|
Life Insurance Beneficiary: |
Spouse - Greta Nichols |
|
Percentage Allocations (if multiple beneficiaries): |
75% to Spouse, 25% to Child - Slater Nichols |
|
Retirement Plan Beneficiary: |
Child - Michael Nichols |
|
Percentage Allocations (if multiple beneficiaries): |
100% to Child - Michael Nichols |
Please indicate if you wish to enroll in any optional benefits.
|
Section 6: Optional Benefits |
||
|
|
Yes |
No |
|
Flexible Spending Account (FSA): |
|
|
|
Health Savings Account (HSA): |
|
|
|
Wellness Program: |
|
|
|
Section 7: Acknowledgment |
|
I acknowledge and understand the following:
● [Your Company Name] reserves the right to amend or terminate benefits plans at any time. ● I have reviewed the benefits plan materials and agree to comply with their terms and conditions. ● I understand that benefits selections made during this enrollment period may remain in effect until the next enrollment period, unless I experience a qualifying life event. |
Employee Signature: [Sample Signature] Date: April 21, 2050
HR Representative Signature: [Sample Signature] Date: April 15, 2050
Please review your selections carefully before signing. If you have any questions or need assistance, contact [Your Company Name] at [Your Company Email Address] or [Your Company Number].
Thank you for completing the Benefits Enrollment Questionnaire. Your selections will be processed, and you will receive confirmation of your benefits enrollment.
