New Hire Benefits Enrollment Form
Personal Information
First Name
Last Name
Date of Birth
SSN
Address
Email
Phone Number
Employment Information
Position
Department
Date of Hire
Employee ID
Benefit Selection
Medical Plan
Plan A
Plan B
Waive
Dental Plan
Plan 1
Plan 2
Waive
Vision Plan
Yes
Waive
Dependent Information
Dependent Name
Relationship
Date of Birth
Other Benefits
Life Insurance (Yes/No)
Yes
No
Disability Insurance (Yes/No)
Yes
No
Comments or Questions