Claim Forms

Georgia.gov

Claim Forms

Below, please find various flexible benefit claim forms to aid in the process of processing a claimed benefit.

CONTACT

Claim Forms
Flexible Benefits Specialist

Phone

404-463-3589

HRA.Flexbenefits@doas.ga.gov

View All Division Contacts

Claim Forms And Documents

SORT BY

05/21/20

Disabled Dependent Certification Form

Form for enrolling children in the Flexible Benefits Program

01/13/15

Specified Illness Claim Form

Form for claim filing for specified critical illness benefits with insurance carrier (CAIC)

01/13/15

Delta Dental Claim Form

Form for claim filing for dental benefits with dental insurance carrier (Delta Dental)

01/13/15

Long Term Care Coverage Form

Form for continuing long term care insurance after termination with long term care insurance carrier (Unum)

01/13/15

Blue View Walmart Claim Form

Form used for when seeing a Sams/Walmart vision care provider not listed under the participating in-network Blue View locations...

01/13/15

Accelerated Benefit Option Claim Form

Form for claim filing for accelerated benefit option with the life insurance carrier (Metlife)

01/13/15

Accidental Death & Dismemberment Claim Form

Form for claim filing for accidental death and dismemberment benefits with the AD&D insurance carrier (Metlife)

01/13/15

Life Waiver of Premium Claim Form

Form for claim filing for waiver of premium due to a total disability with the life insurance carrier (Metlife)

01/13/15

Vision ID Card Printing Instructions

Instructions for printing vision ID card for vision insurance carrier (OptumHealth)

01/13/15

Dependent Care Spending Account Claim Form

Form for claim filing for the dependent care spending account reimbursement with the Spending Account administrator (ADP)

01/13/15

Health Care Spending Account Claim Form

Form for claim filing for the health care spending account reimbursement with the Spending Account administrator (ADP)

01/13/15

Aflac CAIC Specified Illness Health Screening Form

Health Screening form for the Aflac/CAIC Specified Illness product.

10/17/17

How to File a Disability Claim

Instructions for claim filing for disability benefits with disability insurance carrier (The Standard)

10/17/17

Disability Claim Form

Form for claim filing for disability benefits with the disability insurance carrier (The Standard)

07/15/19

Short Term Disability Claim Packet - State of Georgia

Form for claim filing for short term disability with Standard Insurance Company

07/15/19

Long Term Disability Claim Packet – State of Georgia

Form for claim filing for long term disability with Standard Insurance Company.

Claim Forms

CONTACT

RELEVANT LINKS

Human Resource Administration

Claim Forms And Documents

SORT BY

Disabled Dependent Certification Form

Specified Illness Claim Form

Delta Dental Claim Form

Long Term Care Coverage Form

Blue View Walmart Claim Form

Accelerated Benefit Option Claim Form

Accidental Death & Dismemberment Claim Form

Life Waiver of Premium Claim Form

Vision ID Card Printing Instructions

Dependent Care Spending Account Claim Form

Health Care Spending Account Claim Form

Aflac CAIC Specified Illness Health Screening Form

How to File a Disability Claim

Disability Claim Form

Short Term Disability Claim Packet - State of Georgia

Long Term Disability Claim Packet – State of Georgia

Claim Forms

CONTACT

RELEVANT LINKS

Human Resource Administration

Claim Forms And Documents

SORT BY Priority Date File Type Alphabetically

Disabled Dependent Certification Form

Specified Illness Claim Form

Delta Dental Claim Form

Long Term Care Coverage Form

Blue View Walmart Claim Form

Accelerated Benefit Option Claim Form

Accidental Death & Dismemberment Claim Form

Life Waiver of Premium Claim Form

Vision ID Card Printing Instructions

Dependent Care Spending Account Claim Form

Health Care Spending Account Claim Form

Aflac CAIC Specified Illness Health Screening Form

How to File a Disability Claim

Disability Claim Form

Short Term Disability Claim Packet - State of Georgia

Long Term Disability Claim Packet – State of Georgia

SORT BY