Insurance Enrollment and Change Form (Form 1) 
- For state enrollees, housing authority and planning council enrollees enrolling in, changing coverage and/or canceling coverage for:
- Basic Life and Health Insurance enrollment - Note: you may only enroll in coverage as a new hire or during annual enrollment, unless you move out of your plan's service area or can provide proof of loss of coverage elsewhere.
- Basic Life enrollment - only available as a new hire or during annual enrollment
- Optional Life Insurance (Active employees) - may apply for optional life insurance or to change from non-automatic increase to automatic increase at any time. The GIC will notify the life insurance carrier of your application; the carrier will send you a medical application to complete and return. See your GIC Coordinator for a Beneficiary Form.
- Long Term Disability (LTD) for Active Employees - Enroll as a new hire or apply for coverage at any time during the year. The GIC will notify the LTD carrier of your application; the carrier will send you a medical application to complete and return.
- Cancel/Change GIC Coverage - Name Change, Address Change, Leave of Absence, Return to Payroll, Retirement, Agency Transfer, Termination of State Service.
Insurance Data Form (IDF)
- For adding, changing, and deleting a spouse and/or dependent. Must attach required documentation, as listed on the form.
This information provided by the Group Insurance Commission.
