Gage OE Fillable Enrollment Form

Gage Technologies, Inc. Employee Benefits Election Form 2023 EMPLOYEE INFORMATION Dental and Vision benefits will be provided through MetLife. Please complete and return this form even if you are st st declining coverage. Plan year runs June 1 , 2023– May 31 , 2024. Employee Legal Name _____________________________________________ Date of Hire ______/______/_________ Social Security Number ____________-___________-________________ Date of Birth ______/_____/__________ Mailing Address __________________________________ City _________________ State ______ Zip ____________ Gender: Male _____ Female ______ Phone Number __________________________________ Email _________________________________________________________ DENTAL INSURANCE I choose the following dental insurance coverage: oLOW Dental Plan $1000 annual benefit (no ortho) oHIGH Dental Plan $1000 annual benefit (w/ortho children up to 19) oWaive: I choose not to participate in the dental plan this year Please check one of the following coverage categories: Employee Only ______ Employee & Spouse ______ Employee & Children ______ Employee & Family ______ VISION INSURANCE I choose the following vision insurance coverage: oMetLife Vision Plan oWaive: I choose not to participate in the vision plan this year Please check one of the following coverage categories: Employee Only ______ Employee & Spouse ______ Employee & Children ______ Employee & Family ______ *Complete, sign and date back page*

DEPENDENT INFORMATION This mustbe completedifyou areadding a spouse or childrentothe DENTAL or VISION plan. Spouse ___________________________ DOB ____/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F Child ______________________________ DOB ___/____/_______ SS# _______-______-__________ Gender M or F SIGNATURE • I understand the elections I have chosen. I acknowledge that the group’s SummaryPlan Description and Annual Notices are available in the HR Departmentfor my review if needed. • I affirm that I can only make changes to my elections during a qualifying event or during annual open enrollment, ending before June 1, 2022. ___________________________________________ Signature Date