Legal Employment & Labor Benefits Enrollment Form
Welcome to the Legal Employment & Labor Benefits Enrollment Form. This form allows you to select your desired benefits, designate beneficiaries, and specify tax withholdings. Please review the options carefully and complete all sections accurately to ensure efficient processing of your benefits elections. Thank you.
I. Employee Information
Provide your personal details accurately for HR records. Include your full name, employee ID, department, and contact information. Ensure all fields are filled to facilitate efficient communication and benefit administration.
Full Name: | [Your Name] |
|---|
Employee ID: | 123456 |
Department: | Marketing |
Position: | Senior Marketing Specialist |
Date of Hire: | [Month Day, Year] |
Contact Info: | [Your Address] |
| [Your Number] |
| [Your Email] |
II. Benefit Plan Options
Select desired benefit plans and coverage levels. Review premium costs carefully. Indicate choices by marking checkboxes or filling in relevant information. Contact HR for clarification on plan options if needed.
Benefit | Plan Options | Coverage Levels | Premium Costs |
|---|
Health Insurance | Plan A, Plan B | Individual, Family | Employee: $50/month |
| | | Employer: $200/month |
Retirement Plans | 401(k) | 5% contribution | Employer matches 50% |
Life Insurance | Basic Life, Supplemental Life | $50,000 coverage | Employee: $10/month |
Disability Insurance | Short-Term Disability | 60% of salary | Employee: $20/month |
Flexible Spending | Healthcare FSA, Dependent Care FSA | N/A | Employee: N/A |
Vision Insurance | Basic, Enhanced | Individual, Family | Employee: $15/month |
Dental Insurance | Basic, Comprehensive | Individual, Family | Employee: $20/month |
III. Benefit Elections
Check the boxes next to selected benefits and indicate any waivers. Sign and date the form to confirm your benefit choices. Ensure accuracy to avoid processing delays and ensure proper enrollment.
IV. Beneficiary Designations
Name primary and contingent beneficiaries for insurance policies and retirement accounts. Include full names, relationships, and percentage allocations. Double-check information for accuracy and update as necessary.
Primary Beneficiary
Full Name: [Name]
Relationship: Spouse
Percentage Allocation: 100%
Contingent Beneficiary
Full Name: [Name]
Relationship: Child
Percentage Allocation: 100%
V. Tax Withholding Elections
Specify federal and state income tax withholdings. Choose appropriate filing status and exemptions. Consult tax advisors if unsure. Complete all relevant fields accurately to ensure correct tax withholdings from your paycheck.
VI. Acknowledgment and Consent
I acknowledge that the benefit choices indicated above are accurate and understand that my elections may affect my payroll deductions. I also consent to the terms and conditions of the benefit plans selected.
[Month Day, Year]
Employer Use Only
HR Review and Approval:
[Month Day, Year]
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