{"id":4690,"date":"2020-02-07T13:08:50","date_gmt":"2020-02-07T18:08:50","guid":{"rendered":"https:\/\/health.uconn.edu\/human-resources\/?page_id=4690"},"modified":"2025-06-13T14:14:20","modified_gmt":"2025-06-13T18:14:20","slug":"retirement-initiation-packet","status":"publish","type":"page","link":"https:\/\/health.uconn.edu\/human-resources\/retirement-initiation-packet\/","title":{"rendered":"Retirement Initiation Packet"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_9' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'>Eligible employees planning to retire in the near future must complete this at least 3 months prior to the selected retirement date.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/human-resources\/wp-json\/wp\/v2\/pages\/4690' data-formid='9' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_9_35\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_35\" ><h2 class=\"gsection_title\">Demographic Information<\/h2><\/li><li id=\"field_9_1\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_1\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Legal Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_1'>\n                            \n                            <span id='input_9_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_9_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_9_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_9_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_9_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_9_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_4\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_4\" ><label class='gfield_label gform-field-label' for='input_9_4'>Retirement Date (must be the 1st of a month)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_9_4' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_9_4_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_4' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_47\" class=\"gfield gfield--type-fileupload gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_47\" ><label class='gfield_label gform-field-label' for='input_9_47'>Upload a copy of your Retirement Letter<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='104857600' \/><input name='input_47' id='input_9_47' type='file' class='medium' aria-describedby=\"gfield_upload_rules_9_47\" onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_9_47'>Accepted file types: pdf, doc, docx, Max. file size: 100 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_9_47'><\/div><\/div><\/li><li id=\"field_9_5\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_5\" ><label class='gfield_label gform-field-label' for='input_9_5'>Employee Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_9_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_5_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_5' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_6\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_6\" ><label class='gfield_label gform-field-label' for='input_9_6'>Employee Date of Marriage (if married)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_9_6' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_6_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_6_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_6' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_7\" class=\"gfield gfield--type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_7\" ><label class='gfield_label gform-field-label' for='input_9_7'>Employee ID Number (must be 6 digits)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_9_7' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_9_8\" class=\"gfield gfield--type-email gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_8\" ><label class='gfield_label gform-field-label' for='input_9_8'>UConn Health Email Address<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_9_8' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_9_9\" class=\"gfield gfield--type-email gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_9\" ><label class='gfield_label gform-field-label' for='input_9_9'>Personal Email Address<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_9_9' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_9_10\" class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_10\" ><label class='gfield_label gform-field-label' for='input_9_10'>Telephone Number (work)<\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_9_10' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_11\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_11\" ><label class='gfield_label gform-field-label' for='input_9_11'>Telephone Number (home)<\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_9_11' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_48\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_48\" ><label class='gfield_label gform-field-label' for='input_9_48'>Telephone Number (cell)<\/label><div class='ginput_container ginput_container_phone'><input name='input_48' id='input_9_48' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_9_12\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_12\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address as of Retirement Date (cannot be a P.O. box)<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_9_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_9_12_1' value=''    aria-required='false'    \/>\n                                        <label for='input_9_12_1' id='input_9_12_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_9_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_9_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_9_12_2' id='input_9_12_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_9_12_3' value=''    aria-required='false'    \/>\n                                    <label for='input_9_12_3' id='input_9_12_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_9_12_4' value=''      aria-required='false'    \/>\n                                        <label for='input_9_12_4' id='input_9_12_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_9_12_5' value=''    aria-required='false'    \/>\n                                    <label for='input_9_12_5' id='input_9_12_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_9_12_6_container' >\n                                        <select name='input_12.6' id='input_9_12_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_9_12_6' id='input_9_12_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_9_30\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_30\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_13\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_13\" ><h2 class=\"gsection_title\">Retirement Plans<\/h2><\/li><li id=\"field_9_36\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_36\" ><label class='gfield_label gform-field-label' for='input_9_36'>Current Retirement Plan<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_9_36' class='small gfield_select'     aria-invalid=\"false\" ><option value='Choose One' >Choose One<\/option><option value='SERS (Tier I, II, IIA, III)' >SERS (Tier I, II, IIA, III)<\/option><option value='Hybrid' >Hybrid<\/option><option value='Alternate Retirement Plan (ARP)' >Alternate Retirement Plan (ARP)<\/option><\/select><\/div><\/li><li id=\"field_9_18\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_18\" ><h2 class=\"gsection_title\">Benefit Payment Option (select one)<\/h2><\/li><li id=\"field_9_50\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_50\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Option D<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_50'><li class='gchoice gchoice_9_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Straight Life Annuity (no benefits are payable after your death, and health insurance terminates for any dependents enrolled in retiree health insurance.)'  id='choice_9_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_50_1' id='label_9_50_1' class='gform-field-label gform-field-label--type-inline'>Straight Life Annuity (no benefits are payable after your death, and health insurance terminates for any dependents enrolled in retiree health insurance.)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_51\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_51\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Option A<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_51'><li class='gchoice gchoice_9_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='50% Spouse (50% of your payment and lifetime retiree health insurance continues after your death to a surviving spouse.)'  id='choice_9_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_51_1' id='label_9_51_1' class='gform-field-label gform-field-label--type-inline'>50% Spouse (50% of your payment and lifetime retiree health insurance continues after your death to a surviving spouse.)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_52\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_52\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Option B<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_52'><li class='gchoice gchoice_9_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='50% Annuitant \u2013 non-spouse (50% of your payment continues after your death to a survivor.  Only one annuitant may be selected and can never be changed.)'  id='choice_9_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_1' id='label_9_52_1' class='gform-field-label gform-field-label--type-inline'>50% Annuitant \u2013 non-spouse (50% of your payment continues after your death to a survivor.  Only one annuitant may be selected and can never be changed.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='100% Spouse (100% of your payment and lifetime retiree health insurance continues after your death to a surviving spouse)'  id='choice_9_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_2' id='label_9_52_2' class='gform-field-label gform-field-label--type-inline'>100% Spouse (100% of your payment and lifetime retiree health insurance continues after your death to a surviving spouse)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='100% Annuitant \u2013 non-spouse (100% of your payment continues after your death to a survivor.  Only one annuitant may be selected and can never be changed.)'  id='choice_9_52_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_52_3' id='label_9_52_3' class='gform-field-label gform-field-label--type-inline'>100% Annuitant \u2013 non-spouse (100% of your payment continues after your death to a survivor.  Only one annuitant may be selected and can never be changed.)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_53\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_53\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Option C<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_53'><li class='gchoice gchoice_9_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='10 Year Period Certain (If you pass away within first 10 years of retirement, payments continue to annuitant(s) for balance of 10 year period.  Multiple annuitants may be selected.)'  id='choice_9_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_53_1' id='label_9_53_1' class='gform-field-label gform-field-label--type-inline'>10 Year Period Certain (If you pass away within first 10 years of retirement, payments continue to annuitant(s) for balance of 10 year period.  Multiple annuitants may be selected.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='20 Year Period Certain (if you pass away within the first 20 years of retirement, payments continue to annuitant(s) for balance of 20 year period.  Multiple annuitants may be selected.)'  id='choice_9_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_53_2' id='label_9_53_2' class='gform-field-label gform-field-label--type-inline'>20 Year Period Certain (if you pass away within the first 20 years of retirement, payments continue to annuitant(s) for balance of 20 year period.  Multiple annuitants may be selected.)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_54\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_54\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Hybrid<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_54'><li class='gchoice gchoice_9_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Cash-out option'  id='choice_9_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_54_1' id='label_9_54_1' class='gform-field-label gform-field-label--type-inline'>Cash-out option<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_23\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_23\" ><h2 class=\"gsection_title\">ANNUITANT INFORMATION<\/h2><div class='gsection_description' id='gfield_description_9_23'>Please provide the following information for your spouse or annuitant(s).<\/div><\/li><li id=\"field_9_20\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_20\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_20'>\n                            \n                            <span id='input_9_20_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_20.3' id='input_9_20_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_20_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_9_20_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_20.4' id='input_9_20_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_20_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_9_20_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_20.6' id='input_9_20_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_20_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_21\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_21\" ><label class='gfield_label gform-field-label' for='input_9_21'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_21' id='input_9_21' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_21_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_21_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_21' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_22\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_22\" ><label class='gfield_label gform-field-label' for='input_9_22'>Relationship<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_9_22' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Spouse' >Spouse<\/option><option value='Child' >Child<\/option><option value='Dependent' >Dependent<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_9_46\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_46\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_42\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_42\" ><h2 class=\"gsection_title\">ADDITIONAL ANNUITANT INFORMATION<\/h2><div class='gsection_description' id='gfield_description_9_42'>Please provide the following information for your spouse or annuitant(s).<\/div><\/li><li id=\"field_9_43\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_43\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_43'>\n                            \n                            <span id='input_9_43_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.3' id='input_9_43_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_43_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_9_43_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.4' id='input_9_43_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_43_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_9_43_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.6' id='input_9_43_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_43_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_44\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_44\" ><label class='gfield_label gform-field-label' for='input_9_44'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_44' id='input_9_44' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_44_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_44_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_44' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_58\" class=\"gfield gfield--type-text gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_58\" ><label class='gfield_label gform-field-label' for='input_9_58'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_9_58' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_9_49\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_49\" ><h2 class=\"gsection_title\">Health Insurance Elections<\/h2><\/li><li id=\"field_9_64\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_64\" ><label class='gfield_label gform-field-label' for='input_9_64'>Including yourself, how many people will be covered on your plan?<\/label><div class='ginput_container ginput_container_select'><select name='input_64' id='input_9_64' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><\/select><\/div><\/li><li id=\"field_9_68\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_68\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_66\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_66\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_55\" class=\"gfield gfield--type-name gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_55\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_55'>\n                            \n                            <span id='input_9_55_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_55.3' id='input_9_55_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_55_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_9_55_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_55.4' id='input_9_55_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_55_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_9_55_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_55.6' id='input_9_55_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_55_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_56\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_56\" ><label class='gfield_label gform-field-label' for='input_9_56'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_56' id='input_9_56' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_56_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_56_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_56' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_69\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_69\" ><label class='gfield_label gform-field-label' for='input_9_69'>Relationship<\/label><div class='ginput_container ginput_container_select'><select name='input_69' id='input_9_69' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Spouse' >Spouse<\/option><option value='Child' >Child<\/option><option value='Self' >Self<\/option><\/select><\/div><\/li><li id=\"field_9_61\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_61\" ><label class='gfield_label gform-field-label' for='input_9_61'>Medical Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_9_61' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_62\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_62\" ><label class='gfield_label gform-field-label' for='input_9_62'>Dental Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_62' id='input_9_62' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_63\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_63\" ><label class='gfield_label gform-field-label' for='input_9_63'>Eligible for Medicare<\/label><div class='ginput_container ginput_container_select'><select name='input_63' id='input_9_63' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_74\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_74\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_70\" class=\"gfield gfield--type-name gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_70\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_70'>\n                            \n                            <span id='input_9_70_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_70.3' id='input_9_70_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_70_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_9_70_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_70.4' id='input_9_70_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_70_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_9_70_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_70.6' id='input_9_70_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_70_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_78\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_78\" ><label class='gfield_label gform-field-label' for='input_9_78'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_78' id='input_9_78' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_78_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_78_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_78' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_82\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_82\" ><label class='gfield_label gform-field-label' for='input_9_82'>Relationship<\/label><div class='ginput_container ginput_container_select'><select name='input_82' id='input_9_82' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Spouse' >Spouse<\/option><option value='Child' >Child<\/option><option value='Self' >Self<\/option><\/select><\/div><\/li><li id=\"field_9_86\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_86\" ><label class='gfield_label gform-field-label' for='input_9_86'>Medical Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_86' id='input_9_86' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_90\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_90\" ><label class='gfield_label gform-field-label' for='input_9_90'>Dental Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_90' id='input_9_90' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_94\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_94\" ><label class='gfield_label gform-field-label' for='input_9_94'>Eligible for Medicare<\/label><div class='ginput_container ginput_container_select'><select name='input_94' id='input_9_94' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_73\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_73\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_75\" class=\"gfield gfield--type-name gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_75\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_75'>\n                            \n                            <span id='input_9_75_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.3' id='input_9_75_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_75_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_9_75_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.4' id='input_9_75_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_75_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_9_75_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_75.6' id='input_9_75_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_75_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_79\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_79\" ><label class='gfield_label gform-field-label' for='input_9_79'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_79' id='input_9_79' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_79_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_79_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_79' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_83\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_83\" ><label class='gfield_label gform-field-label' for='input_9_83'>Relationship<\/label><div class='ginput_container ginput_container_select'><select name='input_83' id='input_9_83' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Spouse' >Spouse<\/option><option value='Child' >Child<\/option><option value='Self' >Self<\/option><\/select><\/div><\/li><li id=\"field_9_87\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_87\" ><label class='gfield_label gform-field-label' for='input_9_87'>Medical Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_87' id='input_9_87' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_91\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_91\" ><label class='gfield_label gform-field-label' for='input_9_91'>Dental Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_91' id='input_9_91' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_95\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_95\" ><label class='gfield_label gform-field-label' for='input_9_95'>Eligible for Medicare<\/label><div class='ginput_container ginput_container_select'><select name='input_95' id='input_9_95' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_72\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_72\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_76\" class=\"gfield gfield--type-name gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_76\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_76'>\n                            \n                            <span id='input_9_76_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_76.3' id='input_9_76_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_76_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_9_76_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_76.4' id='input_9_76_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_76_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_9_76_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_76.6' id='input_9_76_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_76_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_80\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_80\" ><label class='gfield_label gform-field-label' for='input_9_80'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_80' id='input_9_80' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_80_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_80_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_80' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_84\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_84\" ><label class='gfield_label gform-field-label' for='input_9_84'>Relationship<\/label><div class='ginput_container ginput_container_select'><select name='input_84' id='input_9_84' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Spouse' >Spouse<\/option><option value='Child' >Child<\/option><option value='Self' >Self<\/option><\/select><\/div><\/li><li id=\"field_9_88\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_88\" ><label class='gfield_label gform-field-label' for='input_9_88'>Medical Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_88' id='input_9_88' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_92\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_92\" ><label class='gfield_label gform-field-label' for='input_9_92'>Dental Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_92' id='input_9_92' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_96\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_96\" ><label class='gfield_label gform-field-label' for='input_9_96'>Eligible for Medicare<\/label><div class='ginput_container ginput_container_select'><select name='input_96' id='input_9_96' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_71\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_71\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_77\" class=\"gfield gfield--type-name gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_77\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_9_77'>\n                            \n                            <span id='input_9_77_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_77.3' id='input_9_77_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_77_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_9_77_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_77.4' id='input_9_77_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_77_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_9_77_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_77.6' id='input_9_77_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_9_77_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_9_81\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_81\" ><label class='gfield_label gform-field-label' for='input_9_81'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_81' id='input_9_81' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_81_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_9_81_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_81' class='gform_hidden' value='https:\/\/health.uconn.edu\/human-resources\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_9_85\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_85\" ><label class='gfield_label gform-field-label' for='input_9_85'>Relationship<\/label><div class='ginput_container ginput_container_select'><select name='input_85' id='input_9_85' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Spouse' >Spouse<\/option><option value='Child' >Child<\/option><option value='Self' >Self<\/option><\/select><\/div><\/li><li id=\"field_9_89\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_89\" ><label class='gfield_label gform-field-label' for='input_9_89'>Medical Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_9_89' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_93\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_93\" ><label class='gfield_label gform-field-label' for='input_9_93'>Dental Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_93' id='input_9_93' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_97\" class=\"gfield gfield--type-select gf_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_97\" ><label class='gfield_label gform-field-label' for='input_9_97'>Eligible for Medicare<\/label><div class='ginput_container ginput_container_select'><select name='input_97' id='input_9_97' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Select One' >Select One<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_9_67\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_67\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_98\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_98\" ><h2 class=\"gsection_title\">Retiree Health Medical Plan Election for Non-Medicare Eligible Retirees and\/or Dependents<\/h2><\/li><li id=\"field_9_99\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_99\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Select one of the options below<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_99'><li class='gchoice gchoice_9_99_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.1' type='checkbox'  value='Anthem Primary Care Access [POE-G Plus]'  id='choice_9_99_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_99_1' id='label_9_99_1' class='gform-field-label gform-field-label--type-inline'>Anthem Primary Care Access [POE-G Plus]<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_99_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.2' type='checkbox'  value='Anthem Standard Access [POE]'  id='choice_9_99_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_99_2' id='label_9_99_2' class='gform-field-label gform-field-label--type-inline'>Anthem Standard Access [POE]<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_99_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.3' type='checkbox'  value='Anthem Quality First Select Access [Prime Plus\/Tiered POS]'  id='choice_9_99_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_99_3' id='label_9_99_3' class='gform-field-label gform-field-label--type-inline'>Anthem Quality First Select Access [Prime Plus\/Tiered POS]<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_99_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.4' type='checkbox'  value='Anthem Expanded Access [POS]'  id='choice_9_99_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_99_4' id='label_9_99_4' class='gform-field-label gform-field-label--type-inline'>Anthem Expanded Access [POS]<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_99_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.5' type='checkbox'  value='Anthem State Preferred POS \u2013 Currently Enrolled Only'  id='choice_9_99_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_99_5' id='label_9_99_5' class='gform-field-label gform-field-label--type-inline'>Anthem State Preferred POS \u2013 Currently Enrolled Only<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_99_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.6' type='checkbox'  value='Anthem Out of Area Plan \u2013 Only if Retiree\u2019s Permanent Residence is Outside of Connecticut'  id='choice_9_99_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_99_6' id='label_9_99_6' class='gform-field-label gform-field-label--type-inline'>Anthem Out of Area Plan \u2013 Only if Retiree\u2019s Permanent Residence is Outside of Connecticut<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_99_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.7' type='checkbox'  value='Waive Medical Coverage'  id='choice_9_99_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_99_7' id='label_9_99_7' class='gform-field-label gform-field-label--type-inline'>Waive Medical Coverage<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_102\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_102\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_9_100\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_100\" ><h2 class=\"gsection_title\">Retiree Dental Plan<\/h2><\/li><li id=\"field_9_101\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_101\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Select one of the options below<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_9_101'><li class='gchoice gchoice_9_101_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_101.1' type='checkbox'  value='Basic Dental Plan'  id='choice_9_101_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_101_1' id='label_9_101_1' class='gform-field-label gform-field-label--type-inline'>Basic Dental Plan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_101_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_101.2' type='checkbox'  value='Enhanced PPO Dental Plan'  id='choice_9_101_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_101_2' id='label_9_101_2' class='gform-field-label gform-field-label--type-inline'>Enhanced PPO Dental Plan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_101_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_101.3' type='checkbox'  value='Dental HMO Plan'  id='choice_9_101_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_101_3' id='label_9_101_3' class='gform-field-label gform-field-label--type-inline'>Dental HMO Plan<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_9_101_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_101.4' type='checkbox'  value='Waive Dental Coverage'  id='choice_9_101_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_101_4' id='label_9_101_4' class='gform-field-label gform-field-label--type-inline'>Waive Dental Coverage<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_9_103\" class=\"gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_9_103\" ><label class='gfield_label gform-field-label' for='input_9_103'>CAPTCHA<\/label><div id='input_9_103' class='ginput_container ginput_recaptcha' data-sitekey='6Leu-SYUAAAAAOewrWu56cw55kOz8cfmFyGhWpzJ'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><li id=\"field_9_40\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below 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