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

Dental/Vision Claims

AFLAC – Accident, Critical Illness and Hospital Indemnity

Benefits Termination

Requests for Group Coverage must be made within 31 days of your benefits termination date.

  • Allstate Cancer – Call 1-800-521-3535 to request continuation
  • AFLAC Accident, Critical Illness, Hospital
    • Continuation Form
      or call 800-433-3036 M-F 9AM – 7PM EST
    • Complete the form in its entirety and sign and date it.
    • If paying by monthly ACH/Bank Draft please mail completed forms to: American Family Life Assurance Company (Aflac) P.O Box 641629 Pittsburgh, PA 15264-1629. This payment option is only available on a monthly basis.
    • If paying by check, mail the completed form along with your check to the address noted on the form. This payment option is only available for quarterly, semi-annual or annual payments.
  • AFLAC Term Life
  • Group Life Port/Conversion
  • Genomic Life
  • Unum Life- E-Sign for direct billing
  • Unum LTC – Port Request

In most instances, employees will receive a conservation (continuation) notice direct from the carrier after the coverage has been taken off of payroll billing, except AFLAC (Group Accident, Critical Illness and Hospital) WILL NOT send notices to employees.

Group Life

Disability Insurance

Genomic Life

To continue coverage when terminating, call 800-521-3535

Individual Life Insurance

Long Term Care Insurance