AGENCY FORMS

The Office of Group Benefits (OGB) requires participating agencies to appoint employees as contacts between the agency and OGB. The forms to designate those contacts can be found below. In addition, agencies will find forms for life insurance eligibility, continuation of coverage for a handicapped child, HSA deduction submission and years of participation calculation. If you have questions about a particular form or need assistance, contact OGB Customer Service at 1-844-860-0307.

GB-01 Enrollment/Change Form

New employees complete this form and return to their HR department within 30 days of their hire date. This form can also be used for an enrollee experiencing a qualifying event and needs to make a change to his/her coverage.

GB-74 Designation of OGB Coordinator

The GB-74 form is a designation of the official Agency Benefits Coordinator contact within an agency. This designee will receive most correspondence from OGB. Agencies should complete this form every January or when the designee changes.

GB-75 Designation of Agency Master User

The GB-75 form is a designation of the Master User for eEnrollment purposes within an agency. The Master User can also designate up to 40 sub-users within the agency. This form is completed yearly or when designee changes.

GB-77 Designation of Invoicing Contact

The GB-77 form is a designation of the billing/invoicing contact within the agency. This form is completed when designee changes.

GB-78 Designation of Eligibility/e-Enrollment Contact

The GB-78 is a designation of the person who serves as the eligibility contact for the participating agency. Completed when designee changes.

GB-79 Health Savings Account Enrollment & Payroll Deduction Election/Change Form

Health Savings Account Enrollment & Payroll Deduction Election/Change Form.

HSA Contribution Spreadsheet

The HSA contribution spreadsheet is a means for agencies to submit employee HSA deductions to OGB on a timely basis. This will allow the employees to have access to their HSA funds quicker.

Participation Calculation Form

The Participation Calculation form is used when an agency wishes to calculate how many years of coverage a member has.

Prudential Life EOI – Agency Instructions

Agency instructions on how to fill out the Evidence of Insurability (EOI) form.

Prudential Life Evidence of Insurability Form (EOI)

Agency instructions on how to fill out the Evidence of Insurability (EOI) form.