Payroll / Benefits

• Human Resources Cumulative Beneficiary Change List with links
• Payroll Beneficiary Designation Form
• 2024 Fillable Benefit Election/Change Form
• 2025 Fillable Benefits Election/Change Form
• 457b Plan 3% auto enroll OPT OUT or INCREASE

State Health Medical Forms

• SHBP Retirement/Surviving Spouse Form
• SHBP Employment Transfer Form

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 Life Claim Form
  • Aflac Life Claim Physician Statement (claim within 2 years of issue)
• AFLAC Life Service Form – Changes
• 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 Hospital Indemnity Portability Rates
• Hospital Indemnity – Claim Form and Health Release Authorization  Employer Statement, Physician Statement or file online

FSA – MedCom

• MedCom Forms Library– Pick the one you need
• MedCom Flexible Spending Claim Form
• Direct Deposit Authorization
• Flexible Spending Account Daycare Provider Receipt
• Flexible Spending Account Repetitive Transaction Expense Form
• Flexible Spending Account – Dependent Card Request

Genomic Life

• Continuation after Termination of Employment

Group Life – VOYA

• Evidence of Insurability
• Forms Library
• Employee Portability Request Form
• Spouse Portability Request Form
• Port Rates
• Conversion Request
• Brochure of Conversion
• Proof of Death Claim
• Consumer Privacy Notice

Disability – New York Life

• Intake Brochure – This document provides information on how an employee and the employer can contact NewYork Life to initiate a Disability claim, and also provides an overview of the claims process.

  Online: myNYLGBS.com Register Your Account First. Then choose Coverage>Disability (print your confirmation page)

  By Phone: 888.842.4462 7AM – 7PM CST

Whole Life VOYA / ING

Call 800-537-5024 for Whole Life Questions

• Voya Life Service Request Form or Cancellation Form
• EFT Direct Bill Setup
• Voya Forms Library

Call 888-238-4840 to report a death and start the claims process.

• Application and Underwriting Authorization
  Child Whole Life Rates

Wellness Signup

• Enrollment Form