HUMAN RESOURCES
Forms and Documentation for New Employee
New Employee Memo 
New Employee Orientation 
Form W-4
(IRS Employee's Withholding Allowance Certificate)
Form G-4
(State of Georgia Employee's Withholding Allowance Certificate)
Form I-9
(Employment Eligibility Verification)
ERS Application for Membership
Direct Deposit Form
Worker's Compensation Notice to Employee
Memo - Worker's Compensation Procedure
Employee Acknowledgement of Sexual Harassment Policy
- Sexual Harassment Policy
Employee Information and Emergency Contact
State Application for Employment
Georgia Association of Criminal Defense Lawyers Application for Membership  (For attorneys only)
Georgia Defined Contribution Application for Membership (For part-time employees only)
Employee Assistance Program Brochure
Other Personnel Forms and Documentation
Change of Address/Name Form
Family and Medical Leave Request form
Leave without Pay Request Form
State of Georgia Employee Grievance Form
- Employee Grievance Procedure
Designation of Beneficiary for Compensation
ERS Change of Beneficiary
ERS Group Term Life Insurance Continuation Form
Health Insurance Forms
Request to Continue Health Benefits During Leave of Absence Without Pay
(SHBP 66-003)
This form should be used when a member is placed on approved leave of absence without pay and wishes to continue the coverage on a direct pay basis. Any time a member is not receiving pay but is not terminated from employment, he/she must be reported as on "leave without pay." The member may continue health coverage by paying the appropriate premium directly to the SHBP for the period of approved absence.
Declination of Health Benefit Coverage
(SHBP 66-004)
This form should be used when an employee declines coverage upon employment or is ineligible for coverage due to employment status. (e.g., part-time employee)
Disability Certification
(SHBP 66-005)
This form must be submitted with the request to continue health benefits during a leave of absence without pay due to a disability, including disability for the use of family leave (FMLA).
Dependent Student Status Information
(SHBP 66-082)
This form should be used to update the status of a dependent child who is over the age of nineteen for coverage as a fulltime student. An update is required every twelve months if the member desires to keep a valid identification card showing the student as a covered dependent.
Membership Form/Miscellaneous Update Form
(SHBP 66-090)
This form must be completed by each eligible employee who wishes to enroll or change coverage option or type in any option offered by the SHBP. This form should be used for updating information such as address, or adding or deleting dependents to an existing family contract with the SHBP.
State Non-Tobacco Users Surcharge Waiver Policy
State Non-Tobacco Users Affidavit Form
Release of Information to Personal Representative Form This form should be used to release personal health information to someone other than the patient.
Eligibility Administrative Review Form
Formal Appeal Review Form
Flexible Benefits
Forms
Dental
Disability Claim Packet - State of Georgia
Life & AD&D Claim Forms & Conversion/Portability Information
Life Insurance Underwriting Form
Spending Account Form
Spending Account Claim Form
Specified Illness Forms
Life Insurance Forms
Qualifying Change In Status Form
Summary Plan Descriptions
Employee Life, Spouse Life, Child Life and Accidental Death & Dismemberment
Long Term Care
Dental Regular and PPO Insurance
Legal Insurance
Spending Accounts
Employee's Retirement System
and
Georgia Defined Contribution
ERS Handbook (For full-time employees only)
ERS Plan Description (For full-time employees only)
Georgia Defined Contribution Plan Description (For part-time employees only)
Peach State Reserves
Peach State Reserves has gone paperless!
Now in order to enroll or make changes to your 401K or 457 Plan, you will need to log on to the Peach State Reserves Web site at https://mygapsr.csplans.com. You may also call the Peach State Reserves Information Line at 1-866-MY-GA-PSR (1-866-694-2777), Monday – Friday, 8:00 a.m. to 8:00 p.m.
State Employees Credit Union
Forms
Membership Application
Payroll Deduction Authorization
Checking Account Application
ATM or Debit Card Application
Change of Address Form (For SECU account only)
Information
New Member checklist
Membership Benefits
Membership Information
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