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Employee benefits enrollment template

Here is a basic template for an employee benefits enrollment form: [Company Logo] Employee Benefits Enrollment Form Employee Information:


  • Full Name:

  • Employee ID Number:

  • Mailing Address:

  • Phone Number:

  • Email Address:


Benefit Selection: Please select the benefits you wish to enroll in by checking the appropriate boxes and providing any additional information requested. Health Insurance:


  • Medical:

    • Single Coverage

    • Family Coverage

    • Other (please specify):


  • Dental:

    • Single Coverage

    • Family Coverage

    • Other (please specify):


  • Vision:

    • Single Coverage

    • Family Coverage

    • Other (please specify):


Retirement Plan:

  • 401(k):

  • Contribution percentage:

  • Employer matching percentage (if applicable):

  • Other Retirement Plan (please specify):

  • Vacation and Sick Leave:

  • Vacation Days per year:

  • Sick Days per year:

  • Other Leave (please specify):


Other Benefits:

  • Life Insurance:

  • Coverage amount

  • Disability Insurance:

  • Coverage amount:

  • Other Benefits (please specify):


Acknowledgement and Signature:


  • By signing below, I acknowledge that I have read and understand the terms and conditions of the benefits program, and I authorize the company to deduct any required contributions from my paycheck. I also understand that changes to my benefits selections may only be made during open enrollment periods or in the event of a qualifying life event.

  • Employee Signature:

  • Date:


Please note that this is a basic template, and your employee benefits enrollment form may vary depending on the specific needs and goals of your organization. It is important to ensure that the form includes all the necessary information and instructions for enrolling in the benefits program, and that it complies with all applicable laws and regulations. Additionally, it is important to communicate the benefits program clearly and effectively to employees, highlighting its value and encouraging them to make informed decisions about their benefits.

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