VOLUNTARY BENEFIT PLAN ENROLLMENT FORM



HEALTH CARE PLAN FOR RETIREES OF

CHILDREN’S HOME SOCIETY OF FLORIDA

2011-2012 ENROLLMENT FORM

Any elections left blank or incomplete will be considered “waived.”

| |Gender: M F |Benefits Department Use Only |

|Name:       | | |

| | Form Received: ____/____/____ |

|Street Address:       | |

| | Initials: ____________________ |

|City, State, Zip:       | |

| | | |

|Social Security Number:       |Phone Number:       |Effective Date: ______________ |

| |Date of Retirement:       | |

|Date of Birth:       | | |

|MEDICAL PLAN OPTIONS |

| Aetna HRA HNOption Plan | Retiree Only WAIVE MEDICAL COVERAGE |

|Aetna HRA HNOnly Plan |Retiree and Spouse |

|Panama City, Pensacola and Indian River County: |Retiree and Child(ren) |

|Aetna HRA PPO Plan |Retiree and Family |

|Tallahassee Only: | |

|Capital Health Plan Capital Selection Plan | |

|DENTAL PLAN OPTIONS |

| Aetna Low Option PPO Plan | Retiree Only WAIVE DENTAL COVERAGE |

|Aetna High Option and Passive PPO Plan |Retiree and One Dependent |

| |Retiree and Family |

|VISION PLAN |

| Advantica EyeCare Select Plus 150 Plan | Retiree Only WAIVE VISION COVERAGE |

| |Retiree and Family |

|DEPENDENT INFORMATION |

|You must complete this information if you are electing dependent coverage. If you need additional spaces, please attach another enrollment form. The eligibility of |

|all dependents must be verified. Please contact your local HR Department for information on dependent eligibility verification. |

|Full Name |Relationship |Gender |SSN |Date of Birth |Medical |Dental |Vision |

| | | |(Required) |(Required) | | | |

|      |Spouse | M F |      |      | Yes | Yes | Yes |

| | | | | |No |No |No |

|      |Child | M F |      |      | Yes | Yes | Yes |

| | | | | |No |No |No |

|      |Child | M F |      |      | Yes | Yes | Yes |

| | | | | |No |No |No |

|AUTHORIZATION |

|I understand my benefit choices. I understand and agree that any elections left blank or incomplete will be considered “waived.” These elections replace any previous |

|elections and will terminate the earlier of (1) the last day of the month in which I make my final premium payment, or (2) the last day of the month when I am no |

|longer eligible to participate in the program due to my becoming eligible for Medicare. |

| |

| |

|Signature Date |

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