Open Enrollment Election Form

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

Employee Information

• Full Name
• Employee ID
• Work Email
• Department

Enrollment Details

• Enrollment Period
• Coverage Effective Date
• Enrollment Type
• Qualifying Life Event Date
• Additional Notes
  Use this field only for enrollment-related details that HR needs to process your elections.

Medical Coverage

• Do you want medical coverage?
• Medical Plan Selection
• Coverage Tier
• Dependents Covered Under Medical

Dental and Vision Coverage

• Do you want dental coverage?
• Dental Plan Selection
• Do you want vision coverage?
• Vision Plan Selection

Life Insurance

• Basic Life Insurance Election
• Supplemental Life Coverage Amount
  Enter the amount of supplemental life coverage you want to elect, if available under your plan.
• Primary Beneficiary Name
• Primary Beneficiary Relationship

FSA and HSA Elections

• Do you want to contribute to an FSA?
• FSA Type
• Annual FSA Contribution Amount
• Do you want to contribute to an HSA?
• Annual HSA Contribution Amount

Dependents and Acknowledgement

• Are you enrolling any dependents?
• Dependent Details
• Acknowledgement
• Electronic Signature