Finance Employee Benefits Form

Full Name:	[YOUR NAME]
Department:
Position:
Date of Employment Start:
Salary:

Dependent Information

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Number of Dependents: [2]

Dependent Name	Relationship	Date of Birth
[Mildred Compton]	Spouse	[05/20/2053]

Health Benefits

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Medical Insurance Plan:

• Basic Health

• Enhanced Health Plus

• Custom Plan: [Specify]

Dental Coverage:

• Basic Dental

• Orthodontic

• Custom Plan (please specify): ___________________

Vision Plan:

• Standard Vision

• Premium Vision

• Custom Plan (please specify): ___________________

Retirement Plans

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401(k) Contribution:

• 3%

• 5%

• 7%

• Other: Custom Plan (please specify): ___________________

Stock Options:

• Yes

• No

Additional Benefits

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Annual Bonus:

• Performance-based

• Fixed Amount: [$______]

Tuition Reimbursement:

• Yes

• No

Other Special Benefits: Custom Plan (please specify): __________________

Acknowledgment

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I [YOUR NAME], acknowledge that the information provided is accurate, and I understand the terms and conditions associated with the selected benefits.

 Signature: _________________ Date: [July 10, 2078]

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