Benefits

Overview
Benefit Forms
Contact Us
Benefits Eligibility
Health & Welfare Plans
Retirement Plans
Flexible Spending Accounts
Educational Benefits
Leave & Paid Time Off Programs
Other Benefits
Benefits Links & Resources

Benefits Forms

Note: You will need Adobe Acrobat Reader to open the forms, if you don't have it, you can download a free copy by clicking here.

Mandatory Benefit Forms

• Benefits Waiver Form
• Retirement Election Agreement (If eligible)
• Board of Regent Life Application Form
• Board of Regent Life Beneficiary Form
• Post Mortem Beneficiary
• Staff Classified Employee Handbook Acknowledge Form

Healthcare

Indemnity

• Enrollment Form
• BOR Medical Change Form
• BCBS Change Form
• Medical Claim Form
• Pharmacy Claim Form

High Deductible Plan

• Enrollment Form
• Health Savings Account (HSA) Payroll Deduction Form

PPO

• Enrollment Form
• BOR Medical Change Form
• BCBS Change Form
• Medical Claim Form
• Pharmacy Claim Form

Kaiser HMO

• Enrollment Form
• Change Form

Blue Choice HMO

• Enrollment Form
• BCBS Change Form
• BCBS Cancellation Form

Dental

• Board of Regents Indemnity Dental Enrollment
• Board of Regents Indemnity Dental Claim Form
• MetLife Dental Enrollment Form
• MetLife Dental Claim Form
• Dental Change Form

Vision

• Spectera Vision Enrollment and Change Form
• Spectera Georgia Participating Provider Directory
• Spectera Contracted Retail Chain Providers

Board of Regents Life Insurance plan

• Board of Regents Supplemental and Dependent Life Insurance Application Form
• Board of Regents Life Insurance Beneficiary Designation Form
• Board of Regents Term Life Insurance Change Form

Voluntary Term Life Insurance Plan

• CIGNA Term Life Application Form
• Change Form and Instruction
• Beneficiary Designation Form
• Evidence of Insurability
• CIGNA Term Life Brochure

Personal Accidental Death and Dismemberment Insurance

• Personal Accident Insurance Enrollment Form

Disability

• Short Term and Long Term Disability Enrollment Form
• Evidence of Insurability
• Cancellation Form
• Claim Form

Mandatory Retirement

• Teachers Retirement System of GA Membership Application Form
• American Century
  • Enrollment Form
  • ORP Allocation
  • Notification from American Century Regarding a Change in its International Opportunity Fund
• Fidelity
  • Enrollment Form
  • ORP Allocation
• TIAA-CREF
  • Enrollment Form
  • Personal Information Verification Form
  • Replacement Statement for Group Retirement Annuity(GRA) Certificate
  • Replacement Statement for Life Insurance Policy
  • ORP Allocation
• AIG Retirement (VALIC)
  • Enrollment Form
  • ORP Allocation

Voluntary Retirement

Account Applications:

• American Century:
  • Enrollment Form
  • Salary Reduction Agreement
    
    
• Fidelity:
  • 403(b) Fidelity Enrollment Form
  • Salary Reduction Agreement
    
    
    
• Nationwide:
  • 403(b) Nationwide Enrollment Forms Packet
  • Salary Reduction Agreement
    
    
• TIAA-CREF
  
  403(b) TIAA-CREF Enrollment Form
  • Personal Information Verification Form
  • Replacement Statement for Group Retirement Annuity(GRA) Certificate
  • Replacement Statement for Life Insurance Policy
  • 403(b) & 457 Vender List
  • Salary Reduction Agreement
  • Declaration of Normal Retirement Age

457 TIAA-CREF Enrollment Form

• Personal Information Verification Form
• Replacement Statement for Group Retirement Annuity(GRA) Certificate
• Replacement Statement for Life Insurance Policy
• 403(b) & 457 Vender List
• Salary Reduction Agreement
  

• AIG Retirement (VALIC) :

• Please contact Teresa Harley at 770-596-5117 to complete the Enrollment Form.
• Salary Reduction Agreement
  
  

• Vanguard:
  • 403(b) Vanguard New Account Application and Asset Transfer Form
  • Salary Reduction Agreement
    
    
• 403(b) & 457 Vender List
  
  
• For Fund Transfers, Rollovers or Withdrawals, contact vendor.

Flexible Spending Accounts

• Flex Spending Account Enrollment Form for 2008
• 2008 FSA Health Care Claim Form
• Medical Flexible Spending Account - Notice of Privacy Practices
• 2008 FSA Dependent Care Claim Form
• 2007 SHPS Health Care (FSA) Reimbursement Form
• 2007 SHPS Dependent Care (FSA) Reimbursement Form
• Transportation Spending Enrollment and Change Form
• Transportation Reimbursement Form
• Marta Card Enrollment and Change Form

Path2College 529 Plan

• Path2College 529 Plan Application Form
• Path2College 529 Plan Payroll Deduction Form

Click on the link to access the new site:
http://www.path2college529.com/index_home.html

Tuition Assistance Program

• TAP Application Form

Family Medical Leave Act

• Application for Medical Leave Form (New)
• Healthcare Certification Form
• FMLA Policy (New)

Donated Leave Program

• Donated Leave Donor Transfer Form
• Donated Leave Request Form
• Donated Leave Physician Certificate

Medicare Part D

• Medicare Eligibility Enrollment Form

Misc.

• Employee Voluntary Disclosure Of Disability