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
- All enrollments/changes must be made through the ADP Enrollment Portal: https://myshbpga.adp.com/shbp/
- New Hires can complete the SHBP Enrollment/Decline Form to be input by Benefits/Payroll.
Dental/Vision Claims
- Vision Claim Out of Network – United Healthcare/Spectera
Flexible Spending Accounts
AFLAC – Accident, Critical Illness, Hospital Indemnity and Term Life
- Enrollment Form for New Hires
- Accident claim: Instructions and Accident Claim Form
- Critical Illness: Critical Illness Claim Form
- Hospital Indemnity: Hospital Claim Form
- Aflac Group Service Request/Cancellation Form
- Online Claim Submission (including Wellness Claims)
- Continuation Request – PORT/Continue Coverage upon Termination
- AFLAC Life Claim Form
- Aflac Life Claim Physician Statement (claim within 2 years of issue)
- AFLAC Life Service Form – Changes
Benefits Termination
- Notice for employees on the benefits they may continue.
- MetLife Take along Dental Plan
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.
- Continuation Form
- AFLAC Term Life
- Manage your AFLAC accounts online
https://www.aflac.com/individuals/myaflac/getting-started-guide.aspx
or call 800-992-3522
- Manage your AFLAC accounts online
- Group Life Port/Conversion
- Notice of Conversion and Portability Rights– with request for quote
- Genomic Life
- Portability Form
or call 800-521-3535
- Portability Form
- Unum Life- E-Sign for direct billing
- https://www.unum.com/employees/esign
or call 800-635-5597
- https://www.unum.com/employees/esign
- 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
- The Hartford Life Evidence of Insurability for Alabama.
- The Hartford Life Evidence of Insurability for Georgia.
- The Hartford Conversion Form – to convert Group Life to an Individual Policy at termination.
- The Hartford Life Claim
- Notice of Conversion and Portability Rights– with request for quote.
Disability Insurance
- Hartford Personal Health Information Form– Evidence of Insurability for Alabama.
- The Hartford Life Evidence of Insurability for Georgia.
- Short Term Disability Claim and use policy number GRH-677721
- Long Term Disability Claim and use policy number GLT-677721
Cancer Insurance – Allstate
- Cancer Application New Hires/Guarantee Issue or Annual Enrollment/Evidence of Insurability
- Cancer Claim Form
- Wellness Benefit
Individual Life Insurance
- Unum Service Form (including Cancellation)
- Unum Life Application
- Unum Life Claim
- Grandfathered Policy Termination Request
Liberty National, Texas Life, Alabama Life, Other
Long Term Care Insurance
- Portability – Request to continue coverage