Benefit IRF

General Information
Note: if EMPMSTR3 Forgn Nat Field filled in,check "No" Important for Tax Purposes:
Yes No Yes No
(Check "Y" if going/returning to/from LOA/STD/LTD/WC - **No Marine Crew**)
Yes No Open Enroll Empl. Online
Medical Insurance
PT | AT
Add Change Term New Hire
HMOB Access PPO HDHP
EO EC ES EDP EF E&DP&DPChild EChild&DP
Dental Insurance
PT | AT
Add Change Term New Hire
EO EC ES EDP EF E&DP&DPChild EChild&DP
 
Life Insurance
Add Change Term New Hire 1X 2X 3X 4X
Basic Supp Spouse Child Yes No
 
Dependent Information Required for Spousal & Child Life Insurance
$2,000 $5,000
AD&D
Add Change Term New Hire
Indiv Family
Health FSA
Add Change Term New Hire
Dependent Care
Add Change Term New Hire
403(b)
Yes No
Add Change Term New Hire
Leave of Absence
60% 100%
Dependents - Health/Dental & Life
Yes No
Male Female
Yes No
Male Female
Yes No
Male Female
Yes No
Male Female
Additional Comments
Julie Fawkes    June Sullivan    Linda Snow    Susan Darmofalski