This government document is issued by Department of Juvenile Justice for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://djj.georgia.gov/document/document/voya-accident-insurance-claim-employee-member/download&sa=U&ved=2ahUKEwiPlujOiY2HAxVeg_0HHc1mAF04WhAWegQIAxAB&usg=AOvVaw35xdv0FumNAxN-fLwPRnVi&fexp=72519171,72519168