Cafeteria Plan Benefits Enrollment Form
Personal Information
Full Name
Employee ID
Date of Birth
SSN
Address
Benefit Elections
Medical Insurance
Dental Insurance
Vision Insurance
Flexible Spending Account
Health Savings Account
Dependent Care Account
Coverage Level
Employee Only
Employee + Spouse
Family
Dependent Information
Dependent Name
Date of Birth
SSN
Contribution Amounts
FSA Annual Amount
HSA Annual Amount
Dependent Care Annual Amount
Authorization
Signature
Date