• Hand filling out a form.
  • List of GIC Benefit Coordinators  xlsx format of List of GIC Benefit Coordinators

  • Enrollment/Change Form-1

    This form (Form-1) is for enrolling in, canceling, or changing your election of Health, Basic Life, Optional Life, and Long Term Disability insurance. Use this form as a new hire, at Annual Enrollment, within 60 days of a documented qualifying status change, for an address or name change, and for divorce and remarriage notifications. Use this form to add or drop your spouse and dependent(s) from coverage during Annual Enrollment and within 60 days of a documented qualifying status change.


  • Employment Status Change Form-1A

    Use this form when you have an employment status change including retiring from state service, terminating state service, starting or returning from a leave of absence, and transferring to or from your agency. State Retirees can use this form to change their Optional Life Insurance election amount and to cancel coverage.

  • Dependent Ages 19 to 26 Enrollment/Change Form

    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.
  • Buy-Out for State Employees and Retirees

    If you have access to non-GIC Health Insurance (for example, through your spouse) it may pay to participate in the Buy-out Program.
  • Dental & Vision Form

    Form to enroll in GIC Dental/Vision coverage.

  • Health Care Spending Account (HCSA) Forms

    Enrollment and change and claim forms for the state employee Health Care Spending Account pre-tax program.
  • Dependent Care Assistance Program (DCAP) Forms

    Enrollment, change and claim forms for the state employee Dependent Care Assistance (DCAP) pre-tax program.
  • Marketplace Notice

    This notice, provided to all new hires, provides some basic information concerning your current health insurance coverage and the availability of other coverage.

  • Premium Assistance Notice

    This notice provides information on how to access premium assistance if you or your children are eligible for Medicaid or CHIP.

  • Required Documentation

    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. 

  • Leave of Absence Form (Form-11)

    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 the Leave of Absence Form (Form-11).

  • Employee Acknowledgement Form

    New hires must complete this form to verify that they have been notified about their benefit options.

  • Benefit Statement Change Form

    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.
  • Handicapped Dependent Form

    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.

  • COBRA Forms

    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.
  • Life Insurance Beneficiary Forms

    These forms are used to designate your beneficiary or beneficiaries in the event of your death.
  • Third Party Address Request

    Use this form to set up an address in the GIC’s system that’s different than the insured’s address.  Common requests of this nature are for a divorce/separated spouse, a dependent under age 19 who does not reside with the insured, and for a dependent age 19-26 who lives outside of the service area.

  • Pre-Tax Application

    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.
  • HIPAA Privacy Forms