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.
Enrollment / Changes
Register with the Company ID: CowetaCountySchools
State Health Medical
Enrollment and changes must be completed through the SHBP-ADP Website
Dental and Vision
Cobra – IMS will mail Dental/Vision Cobra Election Notice and Premium Payment Setup once coverage has been terminated.
Out of Network Claims
Group Life and Disability
Evidence of Insurability will be completed electronically through the enrollment system
For online EOI issues, a paper EOI may be accepted.
Disability Claims
Disability Intake Instructions:
https://www.mylincolnportal.com/customer/public/login
Registration Code COWETA
Review the status through the Lincoln Portal
Life Claims
Instructions:Coweta County will initiate the Proof of Death Claim through the Portal
https://www.mylincolnportal.com/customer/public/login
Registration Code COWETA
Review the status of claims through the Lincoln Portal
Continuation of Life Benefits after Termination
Portability Request – please call 1-877-321-1015, Group Number is SA3-890-LF0384-01 to request a quote.
You must submit the Port Form with your premium to continue. Note: Port Rates are not the same as active rates.
Conversion Request– please call 1-877-321-1015, Group Number is SA3-890-LF0384-01
Prior to 2021: Life Voya
- Waiver of Premium Form and Related Required Forms
- Forms for- Group Life Claim & Settlement Option
- Group Life Conversion Request or Group Life Portability Request
Prior to 2021: Disability Voya
- Forms Library – Short/Long Term Disability Claims
- Related Disability Required Forms
Flexible Spending Accounts
- MedCom Forms Library– Pick the one you need.
- MedCom Flex Claim Form and Direct Deposit Authorization
- MedCom In Home Day Care Receipt
- MedCom Flex Dependent Card Request Form
- MedCom Flex Direct Deposit Form
- MedCom Flex Family Status Change Form
- MedCom Flex Enrollment Form
- MedCom Recurring Reimbursement Request
AFLAC Cancer
Claims
- AFLAC Forms Library
- AFLAC- Waiver of Premium when disabled due to Cancer
- AFLAC – Cancer Claim Form
- AFLAC – Wellness Benefit Claim Form for Cancer Policy
- AFLAC – Payment Authorization for Direct Bill, Manual setup or Choose Aflac Always once you have logged into aflac.com for your policy holder service.
- AFLAC Life Claim Form
- Aflac Life Claim Physician Statement (claim within 2 years of issue)
- AFLAC Life Service Form – Changes
- AllState/American Heritage – Cancer Claim Form
Individual Life Claims
- Shenandoah Life, call 1-800-848-5433 or the Houze office at 1-800-523-7135
- Shenandoah Life Claim Packet- Prosperity
- Shenandoah Life Change Form
- Trustmark Life Claim 1-877-201-9373
- Trustmark Life Claim or File a Claim | Trustmark (trustmarkbenefits.com)
- Unum Life Claim call 1-800-874-7481
- Unum Life Claim Form
- RealStar/ING/Voya Life Claim call 1-888-238-4840
Individual Life Service
- Trustmark Beneficiary Change Form or Service Form or Direct Bill Request
- Shenandoah Individual Life – Lost Policy Form
- Shenandoah Individual Life – Change Form
- Shenandoah Individual Life – Cash Surrender Form
- Unum Service Forms Online- E-sign
- Unum Service Form (pages 1-2 are instructions…do not print or return to Unum). Fill in and send pages 3-4.
- Unum Whole Life Application Unum 10/10 Term Life Application
- Voya Surrender Form (old policies)
Voya Accident
- Voya Claim- including Wellness
- Voya Port (continuation) request Employee and Spouse/Child
- Port Rates (CI, ACC, HI) Billed Quarterly
Critical Illness Claim
- Forms Library – Critical Illness and Related Forms
- Wellness Claim Form Group Name: Coweta County Board of Education, Group Number is 31053-1
File online through https://voya.com/claims or fax 844-449-2553 - Critical Illness Employee Claim Form
- Attending Physician Statement
- Health Release Authorization
- Compass Port Form – Must be completed within 31 days of coverage termination
- Port Rates (CI, ACC, HI) Billed Quarterly
Voya Hospital Indemnity
- Voya Hospital Claim
- Voya Hospital Port (continuation) request Employee and Spouse/Child
- Port Rates (CI, ACC, HI) Billed Quarterly
- Wellness Claim- Initiate Online
