Benefits forms
In most cases, new employees will use the MyBenefits@UGA system to enroll for benefits. Print and read the guide for new employees below.
Get the MyBenefits@UGA guide for new employees
Current employees who need to request changes due to IRS-approved "life events" should print and read the change guide below.
Get the MyBenefits@UGA change guide for current employees
Health insurance
Health expense claim form (for Open Access POS and HSA Open Access POS plans)
Health enrollment form for surviving dependent
Employee request to continue health Coverage (COBRA)
Dependent request to continue health coverage (COBRA)
Request to change COBRA health coverage
Fax cover sheet for dependent enrollment documentation
Health change form (for retirees only)
Tobacco affidavit form (for retirees only)
Dental insurance
Dental expense claim
Insurance request for dependent, unmarried students
Dental enrollment form for surviving dependent
Employee request to continue dental coverage (COBRA)
Dependent request to continue dental coverage (COBRA)
Request to change COBRA dental coverage
Fax cover sheet for dependent enrollment documentation
Dental change form (for retirees only outside open enrollment)
Accidental death & dismemberment insurance (AD&D)
"Proof of loss" claim statement (email Employee Benefits or call 706-542-2222)
Long term disability insurance
LTD Statement of Health form
How to file an LTD claim
Short term disability insurance
How to file a short term disability claim
HSA, FSA, LPFSA
Health Savings Account enroll/change (use the MyBenefits@UGA system; get the HSA guide)
Handle all transactions on the HealthHub.com site
Health care flexible spending account lump sum payment application (for terminating & retiring employees only)
Life insurance
After initial automatic enrollment, handle all transactions on the UGA/MetLife site
Retirement & retirees
UGA ORP election form*
ORP election form (required by TRS)
ORP change form*
*(If you enroll or change ORP companies, you must also complete and submit company applications. Company contact information.)
Georgia Defined Contribution Plan (GDCP) reimbursement request form
Bank draft form (for retirees only)
529 Higher Education Savings Plan
Leave
Questions about benefits forms may be directed to benefits@uga.edu or 706-542-2222.
Deember 3, 2012
