These forms are in either a .doc or .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 Human Resources Department. Electronic submission of forms is not permitted, at this time.
Enrollment & State Health
Evidence of Insurability
- Evidence of Insurability Form – Voya/Reliastar Life
MedCom / FSA
Applications
- Whole Life Applications – Voya
- Whole Life Rates – Voya
- Leave Bank Withdrawal Request Form
- Leave Bank Physician’s Statement
- Cancer Enrollment Form– New Hires/Guarantee Issue- AllState
- Cancer Application– includes EOI- AllState
Claims
Voya Group Number 362395
Claim Forms Library – Voya
Online Claim Form – Voya
Disability Claims must submit 3 Claims:
- Claim for the Employee- Employee Completed
- Claim for the Employer- Employer Completed
- Claim for the Physician- Physician Completed
- Group Life Death Claim – Voya
- Individual Life Death Claim – Voya
- Accident Claim Instructions – Voya/ING Group Accident
- Wellness Critical Illness – Voya/ING (Grandfathered Plan)
- Cancer Claim Form – AllState
- Cancer Wellness Benefit Claim Form – AllState
- Critical Illness Claim Form– AllState
- Critical Illness Wellness Benefit Claim Form – Allstate
- MedCom Flex Claim Form
- Avesis Vision Claim Form
Service Requests
- Voya Payroll Service Form
- Voya Cancellation Form
- Cancer Guardian Portability Form
- Accident Direct Bill Request
- Allstate Cancer direct bill 800-521-3535
- Allstate Online Account Setup, including Claims and policy maintenance
Equicor Life (Cigna) – Contact Putnam Human Resources, 706-485-5381
Colonial – Contact 800-325-4368
Continuation after Termination
- Notice for employees on the benefits they may continue
- Employer Paid Basic Life Conversion Request– Converts to a Whole Life Policy/very expensive
- Supplemental Group Life Port Request – Port Terminates at age 70
- Accident Port request Voya. Rates for Accident