These forms are in the .pdf file format. To read and print them you may need to download the latest version of Adobe® Acrobat® Reader (free) from the Adobe site.
All forms must be printed, completed and signed before submission to the Human Resources Department. Electronic submission of forms is not permitted at this time.
Payroll / Benefits
State Health Medical Forms
Dental / Vision
- MetLife Dental – Out of Network Claim
- BlueCross Blue Shield Vision – Out of Network Claim
- Blue Cross Vision Disabled Dependent Determination
Aflac Wellness & Claim Form
- AFLAC Forms Library
- AFLAC Always – Setup Direct Bill
- Payment Authorization for manual setup
- AFLAC Wellness (Accident Policy) Claim Form
- AFLAC Accident Claim Form
- AFLAC Wellness (Cancer Policy) Claim Form
- AFLAC Cancer Claim Form
- AFLAC Waiver of Premium when disabled
Critical Illness and Hospital – VOYA / ING
- Claims Library for All Forms
- Wellness Claim Form Use Group Policy Number 66364-6CCI File Online or fax 844-449-2553
- Critical Illness Claim Form, Employer Statement, Attending Physician Statement, Health Release Authorization or file online
- Portability Request – Employee and Spouse (Must be submitted within 30 days of termination to continue on direct pay) – Critical Illness Portability Rates and Hosptial Indemnity Portability Rates
- Hospital Indemnity – Claim Form and Health Release Authorization Employer Statement, Physician Statement or file online
FSA – MedCom
Genomic Life
- Continuation after Termination of Employment
Group Life – VOYA
Disability – Cigna
- Disability Claims: Online: Cigna.com/customer-forms or Paper Disability Claim Form or
- Call Your Claim In: Call toll-free at 1.800.36.Cigna (24462) or 1.866.562.8421
Whole Life VOYA / ING
Call 888-238-4840 to report a death and start the claims process.
