Open Enrollment Election Form

Collect employee benefit elections during open enrollment, including medical, dental, vision, life insurance, FSA, HSA, and dependent coverage details.

Employee Information

• Employee Name
• Employee ID
• Work Email
• Department

Enrollment Details

• Enrollment Type
• Requested Effective Date
• Qualifying Life Event Reason
• Date of Qualifying Life Event

Medical Coverage

• Enroll in Medical Coverage?
• Medical Plan Selection
• Coverage Tier
• If waiving medical coverage, provide reason

Dental and Vision Coverage

• Enroll in Dental Coverage?
• Dental Plan Selection
• Enroll in Vision Coverage?
• Vision Plan Selection

Life Insurance, FSA, and HSA

• Enroll in Supplemental Life Insurance?
• Requested Coverage Amount
• Enroll in Flexible Spending Account (FSA)?
• FSA Type
• Annual FSA Contribution Amount
• Enroll in Health Savings Account (HSA)?
• Annual HSA Contribution Amount

Dependent Coverage

• Are you enrolling dependents?
• Dependent Details

Acknowledgement and Consent

• I confirm the information provided is accurate and complete.
• I consent to the collection and processing of my PII for benefits administration purposes.
• Employee Signature
• Date Signed