Employee Benefits Auto-Enrollment Eligibility Criteria Checklist Form
Complete this form to determine your eligibility for employee benefits auto-enrollment. Please provide accurate information for each field.
Employee Full Name
*
First Name
Last Name
Employee ID
*
Job Title
*
Department
*
Please Select
Human Resources
Finance
Operations
Sales
IT
Marketing
Other
Date of Hire
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employment Status
*
Active
On Leave
Terminated
Employment Type
*
Full-Time
Part-Time
Temporary/Contract
Average Weekly Hours Worked
*
Work Location
*
Please Select
Headquarters
Remote
Field Office
Other
Probation Period Completed?
*
Yes
No
Submit Eligibility Checklist
Should be Empty: