GIC Insurance Enrollment and Change Form (Form 1) pdf format of    GIC Insurance Enrollment and Change Form  - This form must be completed for all employees terminating state service, and for layoffs and retirement. Indicate coverage continuation election, if applicable - see this web site's Q and A section for your options, as they are dependent on length of state service: 39-week (layoff only), Deferred Retirement, COBRA (must also complete COBRA application), Conversion (contact your health plan for a conversion application).

COBRA Notice, Rates and Application doc format of    cobraappfy15.doc  - for employees to continue health coverage for  up to 18 months after coverage as an insured employee ends. For terminations on or after May1, 2014.

COBRA Notice, Rates and Application doc format of    COBRAappFY14.doc  - for employees to continue health coverage for up to 18 months after coverage as an insured employee ends. For terminations through April 30, 2014. 

HCSA COBRA Notice and Election Form doc format of    COBRA_HCSA_Notice_App.doc  - HCSA Enrollees may elect to contribute to the HCSA account under COBRA by making direct payments on an after-tax basis.

HIPAA Notice of Portability Rights pdf format of    hipaanotice.pdf  - this notice describes certain HIPAA protections available to you under federal law when changing your health insurance coverage.

Non-Group Conversion - For Non-Group conversion, contact your Plan.

GIC Dental/Vision COBRA Application doc format of    dentalvisioncobrafy15.doc  - Employees who leave or retire from state service, who were enrolled in the GIC Dental/Vision plan for managers and staff in the Legislature and Executive Offices may continue dental/vision coverage for up to 18 months through the COBRA provision. The retiree will be billed for 102% of the premium under this option. For terminations on or after May 1,2014

GIC Dental/Vision COBRA Application doc format of    dentalvisioncobraFY14.doc  -  Employees who leave or retire from state service, who were enrolled in the GIC Dental/Vision plan for managers and staff in the Legislature and Executive Offices may continue dental/vision coverage for up to 18 months through the COBRA provision. The retiree will be billed for 102% of the premium under this option. For terminations through April 30, 2014


This information provided by the Group Insurance Commission.