Section 1: Personal Information

Full Name:

Edward Nichols

Employee ID:

123456

Email Address:

[email protected]

Date of Birth:

01/15/2001

Social Security Number (SSN)

123-45-6789

Address:

21 E. Pin Oak Dr. Oakland Gardens, NY 11364

Section 2: Dependent Information

Spouse's Full Name:

Greta Nichols

Spouse's Date of Birth:

05/20/2005

Child 1 Full Name:

Slater Nichols

Child 1 Date of Birth:

03/10/2030

Child 2 Full Name:

Michael Nichols

Child 2 Date of Birth:

08/25/2032

Section 3: Current Benefit Elections

Medical Plan:

PPO Gold

Dental Coverage:

Comprehensive Dental

Vision Insurance:

Vision Plus

Life Insurance:

Basic Life Insurance

Disability Insurance:

Short-term Disability

Retirement Plan Contributions:

10% of Salary

Section 4: Benefit Selections

Medical Plan:

HMO Silver

Dental Coverage:

Dental Basic

Vision Insurance:

Vision Care

Life Insurance:

Enhanced Life Insurance

Disability Insurance:

Long-term Disability

Retirement Plan Contributions:

5% of Salary

Section 5: Beneficiary Information

Life Insurance Beneficiary:

Spouse - Greta Nichols

Percentage Allocations (if multiple beneficiaries):

75% to Spouse, 25% to Child - Slater Nichols

Retirement Plan Beneficiary:

Child - Michael Nichols

Percentage Allocations (if multiple beneficiaries):

100% to Child - Michael Nichols

Section 6: Optional Benefits

Yes

No

Flexible Spending Account (FSA):

Health Savings Account (HSA):

Wellness Program:

Section 7: Acknowledgment

I acknowledge and understand the following:

●     [Your Company Name] reserves the right to amend or terminate benefits plans at any time.

●     I have reviewed the benefits plan materials and agree to comply with their terms and conditions.

●     I understand that benefits selections made during this enrollment period may remain in effect until the next enrollment period, unless I experience a qualifying life event.