This form (Form-1) is for enrolling in or changing your election of health, basic life, option life, and long term disability insurance. Use this form as a new hire, at Annual Enrollment, or within 60 days of a documented qualifying status change to make your elections.
This form is for when you have an employment status change including a leave of absence, transferring to or from your agency, terminating state service, and at retirement. State retirees may use this form to change their Optional Life Insurance Coverage.
- Use this form to add your dependent age 19 to 26 to your coverage as a new employee, during Annual Enrollment, or to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area or when he/she no longer is a full-time student.
- If you have access to non-GIC Health Insurance (for example, through your spouse) it may pay to participate in the Buy-out Program.
Form to enroll in GIC Dental/Vision coverage.
- Enrollment and change and claim forms for the state employee Health Care Spending Account pre-tax program.
- Enrollment, change and claim forms for the state employee Dependent Care Assistance (DCAP) pre-tax program.
This notice, provided to all new hires, provides some basic information concerning your current health insurance coverage and the availability of other coverage.
This notice provides information on how to access premium assistance if you or your children are eligible for Medicaid or CHIP.
A list of the documents you must provide, along with your enrollment application, to join the GIC, to add a spouse or dependent, or when you are retired and you or your covered spouse become Medicare eligible.
New hires must complete this form to verify that they have been notified about their benefit options.
- Use this form to get your GIC records up-to-date. Failure to report changes to your marital status particularly can be very costly to you, as you may be responsible for additional premiums or medical claims.
Form to cover a dependent who became mentally or physically incapable of earning his/her own living prior to age 19; or became permanently and totally disabled and became so on or after age 19 and is under age 26.
- If you are an employee of the Commonwealth of Massachusetts, you have the right to choose COBRA coverage if you lose your group health coverage because your hours of employment are reduced or your employment ends for reasons other than gross misconduct.
- These forms are used to designate your beneficiary or beneficiaries in the event of your death.
- The Commonwealth deducts the state employee's share of basic life and health insurance premiums on a pre-tax basis, unless an employee opts out of this option.
- Employees who are taking an approved leave of absence without pay due to one of the following three conditions (Industrial Accident, Employee's personal illness, or Maternity), may apply to continue part-cost premiums by completing this form.
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