Benefits Enrollment Checklist Template (HR)

Eligibility Verification

1 of 10

Confirm employee eligibility for benefits enrollment based on hire date, employment status, and plan requirements.

Hire Date

Employment Status

Full-Time

Part-Time

Contract

Intern

Hours Worked Per Week (if applicable)

Waiting Period Complete?

Yes

Benefit Eligibility Start Date

Benefit Options Explanation

2 of 10

Ensure the employee understands the available benefit plans, coverage details, and associated costs.

Medical Plan Summary

Dental Plan Summary

Vision Plan Summary

Select Preferred Medical Plan Tier (if applicable)

Bronze

Silver

Gold

Platinum

Employee Contribution Amount (Estimate)

Dependent Coverage Quantity

Important Dates & Deadlines

Enrollment Form Completion

3 of 10

Guide the employee through the accurate completion of enrollment forms, including dependent information.

Employee Name (Legal)

Employee ID

Date of Birth

Marital Status

Single

Married

Divorced

Widowed

Other

Dependent Coverage - Select All That Apply

Spouse

Child (Under 26)

Other Dependent

Dependent Names and Dates of Birth (if applicable)

Primary Contact Method

Phone

Dependent Verification

4 of 10

Collect necessary documentation to verify dependent eligibility and coverage.

Dependent's Legal Relationship to Employee (e.g., Spouse, Child)

Proof of Marriage Certificate (if spouse)

Birth Certificate(s) (for children)

Dependent's Social Security Number (SSN) - Optional

Date of Birth for Each Dependent

Dependent's Residency Status

Full-Time Resident

Part-Time Resident

Additional Information/Notes Regarding Dependent Eligibility

Payment Authorization

5 of 10

Obtain employee authorization for payroll deductions or other payment methods.

Payment Method

Payroll Deduction

Direct Deposit

Personal Check

Bank Account Number (if Direct Deposit)

Routing Number (if Direct Deposit)

Account Type (if Direct Deposit)

Checking

Savings

Employee Signature

Authorization Date

Plan Selection Confirmation

6 of 10

Verify the employee's selected plan options and coverage levels.

Medical Plan Selected?

Plan A

Plan B

Waive Medical Coverage

Dental Plan Selected?

Plan 1

Plan 2

Waive Dental Coverage

Vision Plan Selected?

Plan X

Plan Y

Waive Vision Coverage

Dependent Coverage Level

Effective Date Confirmation

Any Specific Coverage Requests?

Enrollment Deadline Adherence

7 of 10

Confirm enrollment is completed within the designated enrollment period.

Employee’s Enrollment Deadline

Actual Enrollment Submission Date

Did Employee Meet Deadline?

Yes

N/A

Days Late (if applicable)

Reason for Late Submission (if applicable)

Were Extensions Offered?

Yes

System Submission & Confirmation

8 of 10

Ensure forms are submitted through the appropriate system and a confirmation is received.

Submission Date

Confirmation ID

Submission Method

Online Portal

Mail

Confirmation Message (if applicable)

System Status

Pending

Approved

Rejected

Record Keeping & Documentation

9 of 10

Maintain accurate records of enrollment decisions and supporting documentation.

Enrollment Form Received Date

Scanned Enrollment Form

Employee ID

Enrollment Status

Pending

Completed

Rejected

Notes/Comments (if any)

Record Creation Date

Post-Enrollment Communication

10 of 10

Provide employees with access to benefit summaries, ID cards, and other relevant information.

Eligibility Verification

Hire Date

Employment Status

Hours Worked Per Week (if applicable)

Waiting Period Complete?

Benefit Eligibility Start Date

Benefit Options Explanation

Medical Plan Summary

Dental Plan Summary

Vision Plan Summary

Select Preferred Medical Plan Tier (if applicable)

Employee Contribution Amount (Estimate)

Dependent Coverage Quantity

Important Dates & Deadlines

Enrollment Form Completion

Employee Name (Legal)

Employee ID

Date of Birth

Marital Status

Dependent Coverage - Select All That Apply

Dependent Names and Dates of Birth (if applicable)

Primary Contact Method

Dependent Verification

Dependent's Legal Relationship to Employee (e.g., Spouse, Child)

Proof of Marriage Certificate (if spouse)

Birth Certificate(s) (for children)

Dependent's Social Security Number (SSN) - Optional

Date of Birth for Each Dependent

Dependent's Residency Status

Additional Information/Notes Regarding Dependent Eligibility

Payment Authorization

Payment Method

Bank Account Number (if Direct Deposit)

Routing Number (if Direct Deposit)

Account Type (if Direct Deposit)

Employee Signature

Authorization Date

Plan Selection Confirmation

Medical Plan Selected?

Dental Plan Selected?

Vision Plan Selected?

Dependent Coverage Level

Effective Date Confirmation

Any Specific Coverage Requests?

Enrollment Deadline Adherence

Employee’s Enrollment Deadline

Actual Enrollment Submission Date

Did Employee Meet Deadline?

Days Late (if applicable)

Reason for Late Submission (if applicable)

Were Extensions Offered?

System Submission & Confirmation

Submission Date

Confirmation ID

Submission Method

Confirmation Message (if applicable)

System Status

Record Keeping & Documentation

Enrollment Form Received Date

Scanned Enrollment Form

Employee ID

Enrollment Status

Notes/Comments (if any)

Record Creation Date

Post-Enrollment Communication

Employee Name

Welcome Email Content

Benefit Summary Document

Benefit ID Card Sent?

Benefit ID Card Mailing Date

Additional Notes/Communication

Human Resources Management Solution Screen Recording

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