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.

2024 GB-02 Flexible Spending Arrangement Enrollment\Stop Form

New employees wishing to enroll in a Flexible Spending Arrangement 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 or enrolling in an FSA during the annual enrollment period.

2025 GB-02 Flexible Spending Arrangement Enrollment\Stop Form

New employees wishing to enroll in a Flexible Spending Arrangement 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 or enrolling in an FSA during the annual enrollment period.

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-76 Additional Agency Contact(s) Form

The GB-76 form’s purpose is to add additional agency contacts to the email blast list. The additional agency contact is someone who does not have master user privileges but still needs to receive the email updates from OGB.

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.

GB-80 Additional Agency Invoicing Contacts

The GB-80 form’s purpose is to add additional agency Invoicing contacts that can receive emailed PHI. The additional agency contact is someone who does not have master user privileges but still needs to receive the documents such as Monthly OGB Invoices, EMR’s (Enrollee Monitoring Reports), and any other email correspondence on individual members from OGB.

GB-99 Retirement Eligibility Attestation Form

This form must be completed by the employee and the agency HR representative before an employee’s retirement. It must be submitted along with a completed and signed GB-01. Failure to submit this form along with the GB-01 will result in the GB-01 being returned and not processed until the GB-99 is completed and submitted.

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.