Annual Benefits Open Enrollment Election Form

Annual Benefits Open Enrollment Election Form — Form Fields

This hr template includes 9 fields. Capture employee benefits elections during open enrollment including health, dental, vision, and supplemental plans. Free to customize and use on ZenBuild.

• Employee Full Name (text, required)
• Employee Email (email, required)
• Employee ID (text, required)
• Medical Plan Selection (dropdown selection, required) — options: HMO – Employee Only, HMO – Employee + Spouse, HMO – Family, PPO – Employee Only, PPO – Employee + Spouse, PPO – Family, Waive Medical
• Dental Plan Selection (dropdown selection, required) — options: Basic Dental, Enhanced Dental, Waive Dental
• Vision Plan Selection (dropdown selection, required) — options: Vision Plan, Waive Vision
• Supplemental Benefits (checkboxes, optional) — options: Life insurance, Short-term disability, Long-term disability, Critical illness, Hospital indemnity
• HSA Contribution Election (multiple choice, optional) — options: Max IRS limit, Custom amount, No contribution
• HSA Monthly Contribution Amount (if custom) (number, optional)