Benefits Information for City of Fort Lauderdale Employees Only

EFFECTIVE JANUARY 1, 2012 - You or your provider can confirm healthcare coverages by calling the following numbers:

• Cigna is the City's healthcare carrier - Group Number 3335139 (OpenAccessPlus Network for all plans) 1-800-244-6224
• Cigna is the City's Rx provider (RxBIN 600428, RxPCN 00600000) 1-800-244-6224
• Cigna is the City's vision carrier (Vision Service Plan) 1-877-478-7557
• Allstate is the City's GAP carrier (Policy #MG-108 G-91134) - contact SIS 1-800-767-6811

Click on the following icons to enroll in benefits, schedule a meeting, change your address, get information, etc.:

2011 & 2012 Enrollment and Claims Forms

• City Change of Address Form (give the completed form to your timekeeper)
• AvMed Claim Form
• Domestic Partner Affidavit
• Express Scripts Rx Claim Form
• Express Scripts Rx New Patients Home Delivery Form
• Vision Claim Form - 2010
• Vision Claim Form - 2011
• Dental Pre-Treatment Estimate and Claim Forms
  • MetLife/Safeguard Dental Claim Form
  • Guardian Dental Claim Form
• 2011 Flexible Spending Account (FSA) Reimbursement Form
• Standard Death Claim Form
• Standard Term LIfe Insurance - Application
• Standard Term LIfe Insurance - Enrollment, Change, and Beneficiary Form
• Aflac Cancellation Form
• US Legal Application Form
• Wellness Reimbursement Claim Forms
  • Aflac Accident Wellness Reimbursement Form
  • Aflac Cancer Wellness Reimbursement Form
  • Aflac Hospital Wellness Reimbursement Form
  • Allstate Wellness Reimbursement Form

Cigna Forms

• Cigna Medical Claim Reimbursement Form
• Cigna Vision Claim Reimbursement Form
• Cigna Rx Claim Reimbursement Form
• Cigna Rx Mail Order Form

Term Life Insurance

• Standard Term (1-800-348-3226): www.standardlife.com
  • Certificate of Coverage - Group Life Insurance
  • Notice of Plan Change
• Allstate (Gregg Gurdak 954-646-8039)
• Colonial (1-800-325-4368): www.coloniallife.com

Voluntary Allstate, Aflac, Colonial

• Aflac (1-800-992-3522): www.aflac.com
• Allstate (Gregg Gurdak 954-646-8039)
• Colonial (1-800-325-4368): www.coloniallife.com

Section 125 Spending Accounts

• Health & Dependent Care Spending Accounts (954-828-5160)
• Section 125 Flexible Spending Account Handbook - Information for Plan Participants
• Eligible FSA Expenses Quick Reference Guide
• 2011 or 2012 Flexible Spending Account (FSA) Reimbursement Form

Adult Child 26 to 30 Years Old

City of Fort Lauderdale employees can obtain healthcare coverage for their 25- to 30-year-old adult children who do not have health insurance coverage. This new coverage complies with the newly enacted State of Florida Statute 627.6562.

Eligibility restrictions under the new Florida Statute for 25- to 30-year-old adult children are:

• 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)

Enrollment information is available online or by calling the City Benefits Office at 954-828-5188.

• Application for Extended Healthcare for 25- to 30-Year-Old Adult Children