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Run: Open Enrollment Election Form

An Open Enrollment Election Form for collecting benefit choices, dependent coverage, and required acknowledgements in one place. Use it to capture clean, rev...

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Employee Information

Full Name (required)

Employee ID (required)

Work Email (required)

Department

Enrollment Details

Enrollment Period (required)

Coverage Effective Date (required)

Enrollment Type (required)

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? (required)

Medical Plan Selection (required)

Coverage Tier (required)

Dependents Covered Under Medical

Dental and Vision Coverage

Do you want dental coverage? (required)

Dental Plan Selection

Do you want vision coverage? (required)

Vision Plan Selection

Life Insurance

Basic Life Insurance Election (required)

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? (required)

FSA Type

Annual FSA Contribution Amount

Do you want to contribute to an HSA? (required)

Annual HSA Contribution Amount

Dependents and Acknowledgement

Are you enrolling any dependents? (required)

Dependent Details

Acknowledgement (required)

Yes No N/A

Electronic Signature (required)

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Email (required)

Your name (optional)

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