Completing the enrollment form

Either select the eligibility date or to specify a date. If you choose specify date, then a date field is required.

Specify the date of enrollment. This is the Start Date for the Employee Benefit.

Select this check box if the Employee or Spouse/Domestic Partner is a smoker. This field is available when the benefit plan Coverage Type is Coverage Options, used for Health, Dental, and Vision, or Coverage Amount, used for Employee Life, Dependent Life, or Disability.

This field is available for Vacation plans. Specify the number of hours that are being bought or sold. The plan designates whether these are bought or sold.

Select this check box if you do not want the Mass Update action to evaluate this enrollment. There must be an eligibility record for the resource in the benefit plan.

Select this check box to send an email for this enrollment. This is not saved on the employee benefit.

This field is available when the benefit plan’s Coverage Type is Coverage Options. (Used for benefits of type Health, Dental, and Vision.)

This field is available when the benefit plan’s Coverage Type is Coverage Amount. Used for benefits of type Employee Life, Dependent Life, and Disability. If the plan provides coverage based on an amount, then specify the amount.

This field is available when the benefit plan’s Coverage Type is Coverage Amount. (Used for benefits of type Employee Life, Dependent Life, and Disability). To override the system-calculated salary, specify a salary.

This field is available when the benefit plan’s Coverage Type is Coverage Amount. Used for benefits of type Employee Life, Dependent Life, and Disability. If the benefit plan provides coverage in a multiple of salary, then specify the multiple.

Select whether contributions are Pre Tax, After Tax, or Both. This is only required if the plan includes both.

This field is available when the plan has no coverage. Specify Percent of Amount if plan includes both. The default is the percent of amount that was defined for the appropriate contribution record for the plan.

If contribution is pre tax, specify the pre tax contribution. Available only for No Coverage Plans. For example, Defined Benefit, Defined Contribution, Spending Account, HSA, or Stock Purchase. Specify the amount/percent for employee contribution that is pre tax.

Use this field only when the benefit plan’s Coverage Type is No Coverage. (These are Benefit Type of Defined Benefit, Defined Contribution, Spending Account, Health Savings Account, or Stock Purchase.) This field is not available for Benefit Type of Vacation.

If contribution is after tax, specify the after tax contribution. Available only for No Coverage Plans. For example, Defined Benefit, Defined Contribution, Spending Account, HSA, or Stock Purchase. Specify the amount/percent for employee contribution that is after tax.

If this field is used, the Elect After Tax Contribution field shows on the employee's profile after their enrollment is finalized to indicate it is their default election.

Use this field only when the benefit plan’s Coverage Type is No Coverage. (These are Benefit Type of Defined Benefit, Defined Contribution, Spending Account, Health Savings Account, or Stock Purchase.) This field is not available for Benefit Type of Vacation.

This field is available if the benefit plan is set up to create HIPAA 834 transactions. This enables the transaction to be turned off for this specific enrollment action.

If selected, a HIPAA 834 transaction is created. This enables the transaction to be turned off for this specific enrollment action.

If Create Transactions is selected, a reason for this enrollment must be selected.

Specify the Member ID Type to use for the HIPAA transaction.