Benefits forms & links for enrollments/changes

The University of Georgia
Human Resources
215 South Jackson Street
Athens, GA 30602
706-542-2222

The forms below are PDF documents. You must have Adobe Acrobat Reader (free software) installed on your computer to view and print the forms. If you don't have Adobe Acrobat, select the button below.

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Indicates an electronic process using HR Connection, PayFlex, MetLife, or TRS

Print the HRconnection guide

Indicates a paper form to be completed and submitted per form instructions, or other method

Health

Dental

Health insurance enrollment using HRconnection (for new employees only)
Request a change in health coverage using HRconnection
Health expense claim form (for PPO & Indemnity plans)
HSA payroll deduction form (for HSA PPO-enrolled participants ONLY through 12/31/09)
bullet HSA payroll deduction form (for HSA PPO-enrolled participants ONLY eff. 01/01/2010)
Health enrollment form for surviving dependent
Insurance request for dependent, unmarried students
Employee request to continue health Coverage (COBRA)
Dependent request to continue health coverage (COBRA)
Request to change health coverage (COBRA only)

Print the HRconnection guide

For retirees only:

Health insurance change (retirees only)

 

Dental enrollment using HRconnection (for new employees only)
Request a change in dental coverage using HRconnection
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 dental coverage (COBRA only)

Print the HRconnection guide

For retirees only:

Dental insurance change (retirees only)

 
Accidental Death
& Dismemberment
Long Term Disability

Enroll for AD&D coverage using HR Connection (new employees only)
Request a change in AD&D coverage using HR Connection
Designate or change AD&D beneficiaries using HR Connection
Proof of loss claim statement (contact Employee Benefits)

Print the HRconnection guide

Enroll for LTD using HR Connection (new employees only)
LTD Statement of Health form
How to file an LTD claim

Print the HRconnection guide

Dependent Care Spending Account
Health Spending Account

New employees:

Enroll in a dependent care flexible spending account using HRconnection

Current employees:
Request a change in a dependent care account using HRconnection
Dependent Care spending account reimbursement using PayFlex

Print the HRconnection guide

 

New employees:

Enroll in a health flexible spending account using HRconnection

Current employees:
Request a change in a health care flexible spending account using HRconnection
Health flexible spending account reimbursement using PayFlex
Health care flexible spending account lump sum payment application (for terminating & retiring employees only)

Print the HRconnection guide

 

Life
Retirement & Retirees

New employees (establish your account, request optional or dependent coverage, establish your beneficiaries):

Log on to the MetLife secure Web site, establish your account, and make your selections there, OR
Call the MetLife toll-free customer service number: 1-866-492-6983

Current, active employees: to request optional or dependent coverage, change coverage, change beneficiaries, or cancel coverage, you may:
Log on to the MetLife secure Web site, establish your account, and make your selections there, OR
Call the MetLife toll-free customer service number: 1-866-492-6983

For retirees only:

To change beneficiaries:
Log on to the MetLife secure Web site, establish your account, and make your changes there, OR
Call the MetLife toll-free customer service number: 1-866-492-6983

To decrease or cancel optional or dependent life coverage, notify UGA Employee Benefits in writing

Teachers Retirement System (TRS) application for membership (register online after receiving a letter from TRS)

ORP election form **
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 enrollment form
Georgia Defined Contribution Plan reimbursement request form

Bank draft form (for retirees only)

Tax Deferred Savings Plans
Workers' Compensation

Salary reduction agreement/change/cancel 403(b)   457(b)

Workers' Compensation first report of injury
Workers's Compensation Wage Statement

Other

Leave

529 Higher Education Savings Plan
Enrollment • Change • Cancellation

Leave without pay

November 20 , 2009