Benefits Election Forms and Rates

Active Employees:

• 2025 Benefits Rate Sheet- Management and Confidential 
• 2025 Benefits Rate Sheet- IAFF 
• 2025 Benefits Rate Sheet- Teamsters 
• 2025 Benefits Rate Sheet- Temp Full Time 
• 2025 Benefits Rate Sheet- Commissioners 
• 2025 Benefits Rate Sheet--COBRA 
• 2025 Voluntary Benefits Rate Sheet-(ARAG and AFLAC Products) 

Benefits Change Form

• Benefits 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. The premium for an adult child is deducted post-tax and is also in addition to the base medical premium (deducted pre-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)

 2025 Adult Child Verification Form 

Benefits Bridge Individual Healthcare Plan

Employees also have the option to obtain individual medical coverage for their adult dependent child through the ACA Marketplace.  The City's voluntary benefits broker, FBMC, provides a Benefits Bridge program to assist employees, and their covered dependents, with finding and enrolling in individual coverage alternatives. Please see flyer for more details and contact information.

• Benefits Bridge Individual Healthcare Plan 

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 Online Contribution Change Instructions 

MissionSquare Retirement 457 Enrollment Forms

• 457 Online Enrollment Instructions 

Domestic Partner Forms

• Domestic Partner Affidavit
• Domestic Partner Certification of Dependent Status 

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Biometrics/Health Screening Verification Forms

• Health Screening Verification Form-Physicians Not Participating in the Cigna Network 
• Health Screening Verification Form for New Hires 

Health Risk Assessment (HRA) Questionnaire

• Marathon Health Questionnaire

Smoking/Tobacco Use Affidavit

• Smoking/Tobacco Use Affidavit (Retirees)

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

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