Insurance Enrollment Form

Employee Information

Full Name
Employee ID
Department
Position
Date of Hire
Email Address
Contact Number

Medical Insurance Enrollment

Plan Options:

• Basic Plan

• Plus Plan

• Premium Plan

Dependent Name	Relationship	Date of Birth	Social Security Number

Dental Insurance Enrollment

Plan Options:

• Basic Plan

• Plus Plan

Dependent Name	Relationship	Date of Birth	Social Security Number

Vision Insurance Enrollment

Plan Options:

• Basic Plan

• Plus Plan

Dependent Name	Relationship	Date of Birth	Social Security Number

Optional Additional Coverages

• Accident Insurance

• Life Insurance

• Disability Insurance

Please specify details if you opt for any of the above:

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Acknowledgement and Signature:

I hereby certify that the information provided is accurate and complete to the best of my knowledge. I understand that false or misleading information may lead to disqualification from insurance benefits.

Employee Signature	Date

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Please return the completed form to the HR department by [Deadline].

Last Updated: [Month Day, Year]

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