Part-Time Employee Benefits Enrollment Form
Personal Information
First Name
Last Name
Employee ID
Email
Phone Number
Address
Benefits Selection
Health Insurance
Enroll
Waive
Dental Insurance
Enroll
Waive
Vision Insurance
Enroll
Waive
Retirement Plan
Enroll
Waive
Flexible Spending Account
Enroll
Waive
Dependent Information
List Dependents (if any)
Acknowledgement
Employee Signature
Date