{"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>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\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_104\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_104'><span class='gform-field-label__text'>Instagram<\/span><\/label><div class='ginput_container'><input name='input_104' id='input_9_104' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_9_104'>This field is for validation purposes and should be left unchanged.<\/div><\/li><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\"  ><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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Legal Name<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_4'><span class='gform-field-label__text'>Retirement Date (must be the 1st of a month)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_4'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_4'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_4' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_4' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_4' aria-label='Retirement Date (must be the 1st of a month): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_47'><span class='gform-field-label__text'>Upload a copy of your Retirement Letter<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='16777216' \/><input name='input_47' id='input_9_47' type='file' class='medium' aria-describedby=\"gfield_upload_rules_9_47\" onchange='javascript:gformValidateFileSize( this, 16777216 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_9_47'>Accepted file types: pdf, doc, docx, Max. file size: 16 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\"  ><label class='gfield_label gform-field-label' for='input_9_5'><span class='gform-field-label__text'>Employee Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_5'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_5'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_5' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_5' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_5' aria-label='Employee Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_6'><span class='gform-field-label__text'>Employee Date of Marriage (if married)<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_6'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_6'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_6' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_6' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_6' aria-label='Employee Date of Marriage (if married): Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_7'><span class='gform-field-label__text'>Employee ID Number (must be 6 digits)<\/span><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\"  ><label class='gfield_label gform-field-label' for='input_9_8'><span class='gform-field-label__text'>UConn Health Email Address<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_9'><span class='gform-field-label__text'>Personal Email Address<\/span><\/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 gfield--phone-format-standard gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_10'><span class='gform-field-label__text'>Telephone Number (work)<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_9_10' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_9_11\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_11'><span class='gform-field-label__text'>Telephone Number (home)<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_9_11' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_9_48\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_48'><span class='gform-field-label__text'>Telephone Number (cell)<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_48' id='input_9_48' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address as of Retirement Date (cannot be a P.O. box)<\/span><\/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='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/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\"  ><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\"  ><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\"  ><label class='gfield_label gform-field-label' for='input_9_36'><span class='gform-field-label__text'>Current Retirement Plan<\/span><\/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\"  ><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 gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Option D<\/span><\/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 gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Option A<\/span><\/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 gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Option B<\/span><\/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 gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Option C<\/span><\/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 gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Hybrid<\/span><\/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\"  ><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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/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-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_21'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_21'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_21'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_21' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_21' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_21' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_22'><span class='gform-field-label__text'>Relationship<\/span><\/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\"  ><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\"  ><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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/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-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_44'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_44'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_44'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_44' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_44' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_44' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_58'><span class='gform-field-label__text'>Relationship<\/span><\/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\"  ><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\"  ><label class='gfield_label gform-field-label' for='input_9_64'><span class='gform-field-label__text'>Including yourself, how many people will be covered on your plan?<\/span><\/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\"  ><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\"  ><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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your Name<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_56'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_56'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_56'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_56' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_56' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_56' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_69'><span class='gform-field-label__text'>Relationship<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_61'><span class='gform-field-label__text'>Medical Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_62'><span class='gform-field-label__text'>Dental Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_63'><span class='gform-field-label__text'>Eligible for Medicare<\/span><\/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\"  ><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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_78'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_78'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_78'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_78' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_78' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_78' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_82'><span class='gform-field-label__text'>Relationship<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_86'><span class='gform-field-label__text'>Medical Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_90'><span class='gform-field-label__text'>Dental Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_94'><span class='gform-field-label__text'>Eligible for Medicare<\/span><\/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\"  ><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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_79'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_79'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_79'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_79' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_79' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_79' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_83'><span class='gform-field-label__text'>Relationship<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_87'><span class='gform-field-label__text'>Medical Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_91'><span class='gform-field-label__text'>Dental Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_95'><span class='gform-field-label__text'>Eligible for Medicare<\/span><\/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\"  ><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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_80'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_80'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_80'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_80' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_80' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_80' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_84'><span class='gform-field-label__text'>Relationship<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_88'><span class='gform-field-label__text'>Medical Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_92'><span class='gform-field-label__text'>Dental Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_96'><span class='gform-field-label__text'>Eligible for Medicare<\/span><\/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\"  ><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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_81'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_9_81'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_81'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_9_81' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_9_81' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_9_81' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_85'><span class='gform-field-label__text'>Relationship<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_89'><span class='gform-field-label__text'>Medical Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_93'><span class='gform-field-label__text'>Dental Coverage<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_97'><span class='gform-field-label__text'>Eligible for Medicare<\/span><\/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\"  ><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\"  ><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 gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Select one of the options below<\/span><\/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\"  ><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\"  ><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 gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Select one of the options below<\/span><\/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\"  ><label class='gfield_label gform-field-label' for='input_9_103'><span class='gform-field-label__text'>CAPTCHA<\/span><\/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 field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Upon receipt of your request, Human Resources will verify your eligibility to retire on your requested date, and will provide you with a checklist to complete the remaining steps of the retirement process.  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