These forms are in either a .doc or a .pdf file format. To read and print the .pdf 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 Payroll & Benefits Department. Electronic submission of forms is not permitted at this time.
New Hires Enrollments/Qualifying Events
State Health
- All enrollments/changes must be made through the ADP Enrollment Portal: https://myshbpga.adp.com/shbp/
- New Hires can complete the SHBP Enrollment/Decline Form to be input by Benefits/Payroll.
Dental/Vision Claims
- Vision Claim Out of Network – United Healthcare/Spectera
Flexible Spending Accounts
AFLAC – Accident, Critical Illness and Hospital Indemnity
- Enrollment Form for New Hires
- Accident claim: Instructions and Accident Claim Form
- Critical Illness: Critical Illness Claim Form
- Hospital Indemnity: Hospital Claim Form
- Aflac Group Service Request/Cancellation Form
- Online Claim Submission (including Wellness Claims)
Benefits Termination
- Notice for employees on the benefits they may continue.
Group Life
- The Hartford Life Evidence of Insurability for Alabama.
- The Hartford Life Evidence of Insurability for Georgia.
- The Hartford Conversion Form – to convert Group Life to an Individual Policy at termination.
- The Hartford Life Claim
- Notice of Conversion and Portability Rights– with request for quote.
Disability Insurance
- Hartford Personal Health Information Form– Evidence of Insurability for Alabama.
- The Hartford Life Evidence of Insurability for Georgia.
- Short Term Disability Claim and use policy number GRH-677721
- Long Term Disability Claim and use policy number GLT-677721
Cancer Insurance – Allstate
- Cancer Application New Hires/Guarantee Issue or Annual Enrollment/Evidence of Insurability
- Cancer Claim Form
- Wellness Benefit
Individual Life Insurance
Long Term Care Insurance
- Portability – Request to continue coverage