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Benefits Forms

Rehired Retiree Forms for Fiscal Year 2014 (7/1/2013 - 6/30/2014) 

GC Retiree Application
USG Retiree Application
State of Georgia Retiree Application

Rehired Retiree Forms for Fiscal Year 2013 (7/1/2012 - 6/30/2013)

FY 2013 GC Retirees Application Process - This document contains the step-by-step process and the application to receive approval to rehire retirees who retired from Georgia College.

FY 2013 USG Retirees Application Process - This document contains the step-by-step process and the application to receive approval to rehire retirees of the University System of Georgia who did not retire from Georgia College.

FY 2013 State of Georgia Application Process - This document contains the step-by-step process and the application to receive approval to rehire retirees who retired from State of Georgia agencies.

ENROLLMENT FORMS
To access the applicable benefits enrollment forms, please click on the plans below.

Health Insurance (doc)

Dental Insurance (doc)

Vision Insurance (PDF)

Domestic Partner Affidavit (doc)

Document Requirements for Domestic Partner and the Dependents Table (doc)

FAQs for Domestic Partner coverage (doc)

Flexible Spending (FSA) Health Care (PDF)

Flexible Spending (FSA) Dependent Care (PDF)

Health Savings Account (HSA) (PDF)

Board of Regents CIGNA Life Insurance (PDF)

Board of Regents CIGNA Spouse/Child Life Insurance (PDF)

Georgia College Reliance Standard Supplemental Life Insurance (PDF)

Georgia College Reliance Standard Spouse Life Insurance (PDF)

Georgia College Reliance Standard Child Life Insurance (PDF)

Georgia College Reliance Standard Voluntary Accidental Death & Dismemberment Form (PDF)

Georgia College Reliance Standard Life Beneficiary Designation Form (PDF)

Georgia College Reliance Standard Short Term Disability (PDF)

Georgia College Reliance Standard Long Term Disability  (PDF)

Teachers Retirement System of Georgia Application of Membership (PDF)

Teachers Retirement System of Georgia Declination of Membership Form (PDF)

Regents Retirement Plan (ORP) Enrollment Form (PDF)

403(b) Tax Deferred Annuity  (PDF)

457(b) Tax Deferred Annuity (PDF)

OTHER BENEFITS FORMS

Americans with Disability Act (ADA) Forms

ADA Accommodations Health Information Release Waiver  (HTML)

ADA Physician's Medical Request Form (doc)

Disability Insurance Claim Forms

Short Term Disability Claim Form (HTML)

Long Term Disability Claim Form  (HTML)

Family and Medical Leave (FMLA) Forms

FMLA Leave Request Form (doc)

Certification of Health Care Provider for Employee’s Serious Health Condition (PDF)

Certification of Health Care Provider for Family Member’s Serious Health Condition (PDF)

Certification of Qualifying Exigency For Military Family Leave (PDF)

Certification for Serious Injury or Illness of Covered Service member — for Military Family Leave  (PDF)

Medical Evaluation - Return to Work (PDF)

Faculty Request for Extension of Tenure Probationary Period (PDF)

Flexible Spending Information & Forms 

Flexible Spending Eligible Expenses (PDF)

FSA Reimbursement Request Form (PDF)

FSA Online Claim Form (PDF)

FSA Status Change Form (PDF)

FSA Automatic Dependent Care Request Form (PDF)

FSA Medical Necessity Form (PDF)

Health/Dental Insurance Forms

BlueCross/BlueShield Health Benefits Claim Form (PDF)

Consent for Use/Release of Health Information (HIPAA) Form (doc)

Family Status Change Form (PDF)

Notice of Privacy Practices (PDF)

Retiree Benefits Confirmation Statement (doc)

Health Savings Account Information & Forms

HSA Eligible Expenses (HTML)

Optional HSA Account Activation and Maintenance Form (PDF)

HSA Name Change Form (PDF)

HSA Beneficiary Change Form (PDF)

HSA Request for Secondary Card Holder Form (PDF)

HSA Direct Rollover/Transfer Request Form (PDF)

Leave Forms

Annual/Sick Leave Request Form (PDF)

Leave Without Pay Request Form (PDF)

Life Insurance Form

BOARD OF REGENTS (BOR) CIGNA LIFE FORMS

BOR - CIGNA Life Insurance Conversion Form (PDF)

BOR - CIGNA Evidence of Insurability Form (PDF)

BOR - CIGNA Personal Accident Insurance Form (PDF)

BOR - CIGNA's Will Preparation Program (PDF)

GEORGIA COLLEGE (GC) RELIANCE STANDARD LIFE FORMS

GC - Reliance Standard Evidence of Insurability Form (PDF)

Optional Retirement Plan (ORP) Form

ORP Quarterly Change Form (PDF)

Shared Sick Leave Program Forms

Shared Sick Leave Donation Form (New! Online Webform)

Shared Sick Leave Donation Form (PDF)

Shared Sick Leave Application: Request & Physician's Certification Form (PDF)

Tax Deferred Annuity Forms

403(b) Enrollment Form (PDF)

403(b) Cancellation Form (doc)

457(b) Enrollment Form (doc)

457(b) Cancellation Form (doc)

New Procedures for Processing Supplemental Retirement Plan Distributions (doc)

Disbursement Eligibility Certificate - Employee Guide (PDF)

How to Request a Hardship Loan Certificate (PDF)

How to Request an In-service Exchange Certificate (PDF)

How to Request a Loan Certificate(PDF)

TRS Forms

Teacher's Retirement System of Georgia Beneficiary Change (PDF)
(Changes to beneficiaries can be made at anytime during the year.)

Workers Compensation Form

Workers' Compensation Claim Reporting Form (doc)

benefits
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