Please complete the form to apply for the Guardian Group Health & Life Flexi Care Standard Plan

Please note:

1. You must be a JPA member to enroll in the plan.

2. If adding a child (under 18) to the plan, you must send a copy of their birth certificate.

3. On the Member Enrollment Form you will receive after you apply, note that the option you select (option 1 or 2 from the brochure sent) should be put in the remarks section of the form.

4. There is a life insurance component attached to the plan so if you have beneficiaries, their info should be places in the Group Life section and the percentages apportioned to each person.

5. The Group Health section should have the information for any dependents you wish to have on the plan.

6. Fill out the Health history questionnaire for all persons to be on the plan.

7. A JPA service charge of $500 per month will be added to your premium, which will be communicated to you once you select your desired option and number of dependents.

8. Dependents can only be a spouse or your children/ward.

9. We ask that you pay over your monthly premium to JPA by the 15th of the month, in order to ensure we have the monthly total to pay over to Guardian on the 1st of each month. We recommend setting up a standing order or recurring transfer to facilitate this process.