Annual Benefits Renewal Election Form
Employee Information
Full Name
Employee ID
Email
Department
Date
Medical Plan Election
Elect Medical Plan
Waive Medical Plan
If electing, select plan
Plan 1
Plan 2
Plan 3
Dental Plan Election
Elect Dental Plan
Waive Dental Plan
If electing, select plan
Dental Plan 1
Dental Plan 2
Vision Plan Election
Elect Vision Plan
Waive Vision Plan
If electing, select plan
Vision Plan 1
Vision Plan 2
Dependent Information
Dependent Name
Date of Birth
Relationship
Other Benefits
Life Insurance
Disability Insurance
Flexible Spending Account (FSA)
Health Savings Account (HSA)
Employee Signature
Signature
Date