New Submission

LAST NAME*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
FIRST NAME*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
MIDDLE INITIALfield type single line
Input blocked. Maximum character limit of 1 characters reached.
SSN*field type single line
eg. 123-45-6789
Input blocked. Maximum character limit of 4000 characters reached.
ADDRESS 1*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
ADDRESS 2field type single line
Input blocked. Maximum character limit of 4000 characters reached.
CITY*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
State*field type drop-down
ZIP CODE*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
HOME PHONEfield type single line
eg. 123-456-7890
Input blocked. Maximum character limit of 4000 characters reached.
CELL PHONEfield type single line
eg. 123-456-7890
Input blocked. Maximum character limit of 4000 characters reached.
Gender*field type radio button
GenderMALEFEMALE
MARITAL STATUSfield type radio button
MARITAL STATUSSINGLEMARRIED
BIRTH DATE*field type date
MM/DD/YYYY
RETIREMENT DATEfield type date
MM/DD/YYYY
Emailfield type email
SECTION 1: INSTRUCTIONSfield type multi line
Retirees: You may only continue, decrease or cancel coverage; you may not increase coverage. If you cancel a benefit, you cannot elect it at a later date. Please remember to complete the Dependent Information section if you have coverage that includes dependents. If you do not participate in Open Enrollment your current benefits and those of your eligible dependents will roll over.

SECTION 2: RETIREE DENTAL

Cancel Dental?field type checkbox
(Please mark one box only)
Cancel Dental?Cancel Dental
Monthly Rates for Retiree Dentalfield type radio button
Monthly Rates for Retiree DentalDELTA DENTAL DHMO* STANDARD Retiree Only ($9.97)DELTA DENTAL DHMO* STANDARD Retiree & One Dependent ($16.48)DELTA DENTAL DHMO* STANDARD Retiree & Family ($25.17)DELTA DENTAL PPO STANDARD Retiree Only ($38.88)DELTA DENTAL PPO STANDARD Retiree & One Dependent ($76.92)DELTA DENTAL PPO STANDARD Retiree & Family ($123.98)DELTA DENTAL DHMO* ENRICHED Retiree Only ($18.15)DELTA DENTAL DHMO* ENRICHED Retiree & One Dependent ($30.07)DELTA DENTAL DHMO* ENRICHED Retiree & Family ($47.81)DELTA DENTAL PPO ENRICHED Retiree Only ($50.90)DELTA DENTAL PPO ENRICHED Retiree & One Dependent ($100.63)DELTA DENTAL PPO ENRICHED Retiree & Family ($162.27)
* DELTA DENTAL DHMO Plans are not available outside of Florida. NOTE: Dental coverage is not provided to Adult Children (AC).

SECTION 3: RETIREE VISION

NOTE: Vision coverage is not provided to Adult Children (AC).

Cancel Vision?field type checkbox
Cancel Vision?Cancel Vision
Monthly Rates for Retiree Visionfield type radio button
Monthly Rates for Retiree VisionDAVIS Base Retiree Only ($4.14)DAVIS Base Retiree & One ($8.30)DAVIS Base Retiree & Family ($15.23)DAVIS Premier Retiree Only ($9.95)DAVIS Premier Retiree & One ($21.39)DAVIS Premier Retiree & Family ($41.29)

SECTION 4: RETIREE & DEPENDENT INFORMATION

(Please list below a Preferred Provider(PDP) if enrolling in a DHMO Dental Plan.)
×
- Relationship*field type drop-down
- Gender*field type drop-down
- Last Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- First Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- SSNfield type single line
  eg: 123-45-6789 - Not including a SSN can delay processing your form.
  Input blocked. Maximum character limit of 4000 characters reached.
- Coveragesfield type checkbox
  CoveragesDentalVision
  Check all that apply
- Date of Birth*field type date
  MM//DD/YYYY
- List PDP of your Dental Providerfield type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Domestic Partner/Child of Domestic Partner or Adult Child:field type radio button
  Domestic Partner/Child of Domestic Partner or Adult Child:Domestic Partner/Child of Domestic PartnerAdult Child
- If enrolling Domestic Partner, Child of Domestic Partner or Adult Child(ren) please select appropriate box.
  
  NOTE: You may only continue or cancel dependent coverage. You may not add new dependents.
Add Dependent
field type multi line
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. F.S. Section 817.234 (1) (b)
Signature*field type signature
Date Signed*field type date

2025 JACKSON HEALTH SYSTEM RETIREE ENROLLMENT FORM

SECTION 2: RETIREE DENTAL

SECTION 3: RETIREE VISION

SECTION 4: RETIREE & DEPENDENT INFORMATION

(Please list below a Preferred Provider(PDP) if enrolling in a DHMO Dental Plan.)