Beauty Through The Lens · L.L.C. · Controlled Form

State of New Jersey · NAICS 541921

BTL-PBL-05 · Volume 05

Medical & Group Benefits Enrollment

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Enrollment/waiver form for group medical, dental, vision, life, disability, HSA/FSA, and retirement (401(k)/SIMPLE IRA). Includes ACA offer of coverage, HIPAA special enrollment, Section 125 pre-tax election, and beneficiary designations. ERISA / ACA / HIPAA / IRC § 125 compliant.

BTL-PBL-05.015

Form

Vol 05 — Human Resources & Talent

Employee

Full name *

Date of birth *

SSN *

Hire / eligibility date *

Enrollment reason *— New hire · Open enrollment · Qualifying life event (HIPAA special enrollment).

Qualifying event & date (if applicable)— Marriage, birth/adoption, loss of coverage, etc. — must enroll within 30 days (60 for CHIP/Medicaid).

Medical Plan

Elected plan *— PPO · HDHP with HSA · HMO · Waive coverage.

Coverage tier *— Employee only · Employee + spouse · Employee + child(ren) · Family.

Per-pay employee premium (pre-tax under IRC § 125)

Dental & Vision

Dental plan / tier

Vision plan / tier

Life & Disability

Basic life (employer-paid)

Yes / N/A

Voluntary supplemental life amount

Short-term disability election

Yes / N/A

Long-term disability election

Yes / N/A

Tax-Advantaged Accounts

HSA annual contribution (HDHP only, IRS limit)

Healthcare FSA annual contribution

Dependent Care FSA annual contribution

Commuter / transit annual contribution

Retirement

401(k) / SIMPLE IRA participation

Yes / N/A

Deferral % (traditional pre-tax)

Deferral % (Roth)

Investment elections attached

Yes / N/A

Dependents (attach additional pages if needed)

Dependent 1 — name / relationship / DOB / SSN / gender

Dependent 2 — name / relationship / DOB / SSN / gender

Dependent 3 — name / relationship / DOB / SSN / gender

Beneficiaries (life & retirement)

Primary beneficiary — name / relationship / DOB / SSN / % *

Contingent beneficiary — name / relationship / DOB / SSN / %

Waivers & Notices

I decline medical coverage and confirm I have alternative coverage (spouse/parent/marketplace/Medicare/Medicaid).— Waiving may not be reversed until next open enrollment absent a HIPAA qualifying event.

Yes / N/A

I received the Summary of Benefits & Coverage (SBC), Notice of Privacy Practices (HIPAA), COBRA General Notice, CHIP Notice, and Marketplace Coverage Notice. *

Yes / N/A

Section 125 pre-tax election — I authorize pre-tax payroll deductions for elected benefits and acknowledge elections are irrevocable during the plan year absent a qualifying event. *

Yes / N/A

Signature

Employee signature *

Date *

Plan administrator signature

Prepared by

Name · Title · Date

Reviewed by

Name · Title · Date

Approved by

Owner · Katheryn L. Wilkins · Date

Controlled document — BTL-PBL-05.015. Complete all required fields (marked *). Retain per Volume 15 retention schedule.