Enroll or Make Changes

I understand that the effective date of my coverage will be delayed if I am not in active employment because of an injury, sickness, temporary lay-off or leave of absence on the date this insurance would otherwise become effective. By clicking the "yes" box I am certifying that I have read and understand the policy information provided, including all statements regarding exclusions.

(If you have not read the information, or do not understand portions of the information, click the "back arrow" on the tool bar to return to the information page. If you have additional questions call Kelley Phillips, Life Solutions, P.A., at 850-524-4240 , or e-mail [email protected].)

50% of salary

40% of salary

25% of salary

Yes, I want to participate. By submitting this form I authorize my employer to deduct from my salary or wages the necessary premium for this coverage and that all the information contained in this form is true and accurate.