HR Open Enrollment Checklist Form

Full Name

First NameLast Name

Employee ID

Work Email Address

example@example.com

Have you reviewed your current benefits elections for the upcoming year?

Do you need to update any dependent or beneficiary information?

Current Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Select the benefits you wish to enroll in for this year

Have you read and acknowledged the open enrollment policies and notices?

Preferred contact method for follow-up (if needed)

Questions or comments regarding your open enrollment