New Submission

Employee Information

Supersede:*field type radio button
Supersede:YesNo
Does this form supersede?
Last Name:*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
First Name:*field type single line
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Middle Initial:field type single line
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SSN:*field type single line
eg. 123-45-6789
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Street Address:*field type single line
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Address 2:field type single line
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City:*field type single line
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State:*field type drop-down
Zip:*field type single line
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Home Phone:field type single line
eg. 999-999-9999
Input blocked. Maximum character limit of 4000 characters reached.
Cell Phone:field type single line
eg. 999-999-9999
Input blocked. Maximum character limit of 4000 characters reached.
Gender:*field type radio button
Gender:MALEFEMALE
Marital Status:field type radio button
Marital Status:SINGLEMARRIED
Birth Date:*field type date
Benefits Effective Date (MM/DD/YYYY):field type date
SECTION 1: INSTRUCTIONSfield type multi line
Retirees: You may only continue, decrease or cancel coverage; you may not increase coverage. Your selection will be effective January 1, 2025. Please note that all cancellations are IRREVOCABLE. 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 continue for the 2025 plan year.

SECTION 2: RETIREE MEDICAL (Please mark one box only)

Cancel Medical:field type checkbox
Cancel Medical:Cancel Medical
Dependent Coverage Only:field type radio button
MEDICAL (Please select one)
Dependent Coverage Only:Spouse/DP Only Jackson First HMO Plan ($883.95)Spouse/DP Only Select HMO Plan ($931.41)Spouse/DP Only POS Plan ($1,903.05)Child(ren) Only Jackson First HMO Plan ($759.41)Child(ren) Only Select HMO Plan ($800.23)Child(ren) Only POS Plan ($1,420.59)Spouse/DP and Child(ren) Jackson First HMO Plan ($1,254.60)Spouse/DP and Child(ren) Select HMO Plan ($1,322.03)Spouse/DP and Child(ren) POS Plan ($3,093.63)

SECTION 3: RETIREE DENTAL

(Please mark one box only)

Cancel Dental:field type checkbox
Cancel Dental:Cancel Dental
Monthly Rates for Retiree Dental:field type radio button
* Delta DHMO plans are not available outside of Florida
Monthly Rates for Retiree Dental:DELTA 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)

SECTION 4: RETIREE VISION

Cancel Vision:field type checkbox
Cancel Vision:Cancel Vision
Monthly Rates for Retiree Vision:field type radio button
NOTE: Vision coverage is not provided to Adult Children (AC).
Monthly Rates for Retiree Vision:DAVIS 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 5: 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.
- SSN:*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Dependent Resident Outside Miami-Dade, Broward or Palm Beach Area:*field type radio button
  Dependent Resident Outside Miami-Dade, Broward or Palm Beach Area:YESNO
- Coverage Desired:field type checkbox
  Coverage Desired:MedicalDentalVisionConstant Credit
- Date Of Birth:*field type date
- PDP #:field type single line
  List the PDP # of your Dental Provider
  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

SECTION 6: LIFE INSURANCE AND VOLUNTARY BENEFITS.

ARAG Legal Product:field type radio button
ARAG Legal Product:Ultimate Advisor Retiree Only ($13.43)Ultimate Advisor Retiree + Family ($17.73)Ultimate Advisor Plus Retiree Only ($18.07)Ultimate Advisor Plus Retiree + Family ($23.84)Cancel ARAG LEGAL
Ocenture ID Commander:field type radio button
Ocenture ID Commander:Retiree Only ($10.50)Retiree + Family ($22.50)Cancel OCENTURE ID COMMANDER
Ocenture ConstantCredit:field type radio button
Ocenture ConstantCredit:Retiree Only ($11.50)Retiree + Spouse ($23.00)Cancel Ocenture ConstantCredit
*Please provide dependent in SECTION 2 if electing dependent coverage.
Pet Assure Plan:field type radio button
Pet Assure Plan:Pet Assure ($8.00)PETplus Single Pet ($4.50)PETplus Multiple Pet ($8.50)Pet Assure/PETplus Single Pet ($12.50)Pet Assure/PETplus Multiple Pet ($16.50)Cancel Pet Assure
Life Insurance:*field type radio button
Life Insurance:Continue LIFE INSURANCECancel LIFE INSURANCE
Life Insurance Selection:*field type radio button
Life Insurance Selection:$5,000 - 65 - 69 ($2.85)$5,000 - 70 - 74 ($4.70)$5,000 - 75 + ($6.50)$10,000 - 65 - 69 ($5.70)$10,000 - 70 - 74 ($9.40)$10,000 - 75 + ($13.00)$15,000.00 - 65 - 69 ($8.55)$15,000.00 - 70 - 74 ($14.10)$15,000.00 - 75 + ($19.50)$20,000.00 - 65 - 69 ($11.40)$20,000.00 - 70 - 74 ($18.80)$20,000.00 - 75 + ($26.00)
Premiums Payment Type:field type radio button
Premiums Payment Type:ACHDirect BillFRSPHT
Document Upload:field type file upload
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Attach and upload documents:
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)
field type multi line
I understand that my active insurance will end at the end of the pay period in which I experienced a regular insurance deduction (or made direct payment to Jackson Health System). I also understand that I have a one-time opportunity to change my election within 30 days of my separation date. I must complete paperwork with the retirement counselor by appointment within the 30-day window to make any changes. After the 30- day window, I will forfeit my right to make any changes to the retirement benefits.
Signature:*field type signature
Date Signed:*field type date

2025 BENEFIT ENROLLMENT FORM FOR RETIREES 65 AND OVER AND/OR MEDICARE ELIGIBLE

Employee Information

SECTION 2: RETIREE MEDICAL (Please mark one box only)

SECTION 3: RETIREE DENTAL

SECTION 4: RETIREE VISION

SECTION 5: RETIREE & DEPENDENT INFORMATION

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

SECTION 6: LIFE INSURANCE AND VOLUNTARY BENEFITS.