Part-Time Employee Benefits Enrollment Form
Personal Information
First Name
Last Name
Email
Phone Number
Address
Date of Birth
Employee ID
Employment Details
Department
Date of Hire
Position
Select Benefits
Health Insurance
Dental Insurance
Vision Insurance
Life Insurance
Retirement Plan
Coverage Type
Employee Only
Employee + Spouse
Employee + Child(ren)
Family
Dependent Information
Dependent Name
Relationship
Date of Birth
Dependent Name
Relationship
Date of Birth
Authorization
Signature
Date