Employee Onboarding Benefits Enrollment Form
Personal Information
First Name
Last Name
Email Address
Phone Number
Employee ID
Department
Benefit Selections
Health Insurance
Plan A
Plan B
Waive
Dental Insurance
Plan A
Plan B
Waive
Vision Insurance
Plan A
Plan B
Waive
Life Insurance
Basic
Supplemental
Waive
Retirement Plan Enrollment
401(k)
403(b)
Waive
Dependents
Dependent Name
Relationship
Date of Birth
Dependent Name
Relationship
Date of Birth