Employee Benefits Plan Selection Form
Review and select your benefits plan options for the upcoming plan year.
Full Name
*
First Name
Last Name
Employee ID
*
Department
*
Please Select
Human Resources
Finance
Operations
Sales
Marketing
IT
Other
Plan Year
*
Please Select
2026
2027
Medical Plan Selection
*
Basic Medical Plan
Enhanced Medical Plan
High Deductible Health Plan (HDHP)
Waive Medical Coverage
Dental Plan Selection
*
Standard Dental Plan
Premium Dental Plan
Waive Dental Coverage
Vision Plan Selection
*
Vision Plan
Waive Vision Coverage
Retirement Plan Options
*
401(k) Plan Enrollment
Roth 401(k) Option
Not Enrolling in Retirement Plan
Additional Benefits (select all that apply)
Flexible Spending Account (FSA)
Health Savings Account (HSA)
Commuter Benefits
Life Insurance
Disability Insurance
None of the above
Comments or Special Requests
Submit Benefits Selection
Should be Empty: