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Run: Open Enrollment Election Form

Open Enrollment Election Form for collecting employee benefit choices, dependent coverage, and required acknowledgements in one place. Use it to standardize ...

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Employee Information

Employee Name (required)

Employee ID (required)

Work Email (required)

Department

Enrollment Details

Enrollment Type (required)

Requested Effective Date (required)

Qualifying Life Event Reason (required)

Date of Qualifying Life Event (required)

Medical Coverage

Enroll in Medical Coverage? (required)

Medical Plan Selection (required)

Coverage Tier (required)

If waiving medical coverage, provide reason

Dental and Vision Coverage

Enroll in Dental Coverage? (required)

Dental Plan Selection (required)

Enroll in Vision Coverage? (required)

Vision Plan Selection (required)

Life Insurance, FSA, and HSA

Enroll in Supplemental Life Insurance? (required)

Requested Coverage Amount (required)

Enroll in Flexible Spending Account (FSA)? (required)

FSA Type (required)

Annual FSA Contribution Amount (required)

Enroll in Health Savings Account (HSA)? (required)

Annual HSA Contribution Amount (required)

Dependent Coverage

Are you enrolling dependents? (required)

Dependent Details (required)

Acknowledgement and Consent

I confirm the information provided is accurate and complete. (required)

Yes No N/A

I consent to the collection and processing of my PII for benefits administration purposes. (required)

Yes No N/A

Employee Signature (required)

Date Signed (required)

Get your results

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Email (required)

Your name (optional)

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