Jeff Overweg, Director
215 South Jackson Street
Athens, GA 30602-4133
706-542-2222

Benefits Forms Most of 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. Health Dental Health enrollment Express Scripts claim Health change Health expense claim (for PPO & Indemnity plans) Health enrollment for surviving dependent Insurance request for dependent, unmarried students Employee request to continue health coverage (COBRA) Dependent request to continue health coverage (COBRA) Dental enrollment (for new employees only) Dental change Dental expense claim Insurance request for dependent, unmarried students Dental enrollment for surviving dependent Employee request to continue dental coverage (COBRA) Dependent request to continue dental coverage (COBRA) Accidental Death & Dismemberment Long Term Disability AD&D Enrollment AD&D Beneficiary Designation AD&D Change Proof of loss claim statement (contact Employee Benefits) LTD Enrollment LTD Statement of Health LTD claim Dependent Care Spending Account Med-Flex (Medical) Spending Account Dependent Care enrollment Dependent Care reimbursement request Dependent Care change Sample receipt for providers Med-Flex enrollment Med-Flex reimbursement request Med-Flex change Life Retirement & Retirees Life enrollment (for new employees only) Life beneficiary designation Life statement of health Life claim (contact Employee Benefits) Georgia Defined Contribution Plan enrollment Georgia Defined Contribution Plan reimbursement request Optional Retirement Plan (ORP) enrollment (contact Employee Benefits) Bank draft (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

Human Resources | The University of Georgia

June 12 , 2007