Benefits Enrollment
HR-031
Page 1 of 1
Employee
Employee Name
Employee ID
Department
Manager
Medical Plan
PPO
HMO
High-Deductible + HSA
Waive
Dental
Enroll
Waive
Vision
Enroll
Waive
Dependents
Number of Dependents
Employee Signature
Date
Confidential · Acme Corporation HR
HR-031 · Benefits Enrollment · Page 1 of 1
