Benefits Election Forms and Rates

Active Employees:

• 2024 Benefits Rate Sheet – Management and Confidential 
• 2024 Benefits Rate Sheet – IAFF
• 2024 Benefits Rate Sheet – Teamsters 
• 2023 Benefits Rate Sheet – Temp Full-Time 
• 2024 Benefits Rate Sheet – Commissioners 
• 2024 Voluntary Benefits Rate Sheet (ARAG and Aflac Products) 

Benefits Change Forms

• Change in Status Form
• Health Benefits Election Change Form

Adult Dependent Child 26- to 30-Years-Old

City of Fort Lauderdale employees may obtain medical coverage for their 26- to 30-year-old adult dependent children who do not have medical insurance coverage. This coverage complies with Florida Statute 627.6562. The premium for an adult dependent child is deducted post-tax.

Eligibility restrictions under the Florida Statute for 26- to 30-year-old adult dependent children are all of the following:

• The child is dependent upon the covered employee for support,
• The child is living in the household of the covered employee, or the child is a full or part-time student,
• Child is unmarried and does not have dependents of their own
• Is a resident of Florida or, if out-of-state, is a full or part-time student; and,
• Does not have any other health insurance coverage (including Medicare)

For enrollment information please call the City Benefits Office at 954-828-5160.

Cigna Forms (Medical, Pharmacy, Dental)

• Cigna Medical Claim Reimbursement Form
• Cigna Rx Claim Reimbursement Form
• Cigna Rx Mail Order Form 
• Cigna DPPO Dental Claim Reimbursement Form 

Deferred Compensation Retirement Plans

Nationwide 457 Enrollment/Change Forms

• Nationwide (NRS) 457 Payroll Authorization Form 

MissionSquare Retirement 457 Enrollment Forms

• 457 Online Enrollment Instructions
• 457 Plan & Roth IRA Contribution Form 
• Roth IRA Information Flyer

Domestic Partner Forms

• Domestic Partner Affidavit
• Domestic Partner Certification of Dependent Status 

Biometrics/Health Screening Verification Form If Using a Practitioner Not in the Cigna Network

• Health Screening Verification Form 

Health Risk Assessment (HRA) Questionnaire

• Marathon Health Questionnaire

Smoking/Tobacco Use Affidavit

• Smoking/Tobacco Use Affidavit (Active Employees)
• Smoking/Tobacco Use Affidavit (Retirees)

Term Life Insurance

• Life Enrollment/Beneficiary Designation Form
• Evidence of Insurability Form/Medical History Statement 

Wellness Incentive Program

For Federation of Public Employees Group Not Enrolled in a Medical Plan with the City Only

• Wellness Incentive Program Tracker Form (Federation Employees Only)
• Wellness Incentive Program Physician Verification Form (Federation Employees Only)

• Wellness Incentive Program Tracker Form (Employee Enrolled in Medical Plan as Spouse/DP of Another Employee)
• Wellness Incentive Program Physician Verification Form  (Employee Enrolled in Medical Plan as Spouse/DP of Another Employee)

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