GIC Insurance Enrollment and Change Form (Form 1) 
- 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&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 - for employees to continue health coverage for up to 18 months after coverage as an insured employee ends. For terminations prior to May 1, 2012.
COBRA Notice, Rates and Application 
- for employees to continue health coverage for up to 18 months after coverage as an insured employee ends. For termination on or before April 30, 2013.
COBRA Notice, Rates and Application
- for employees to continue health coverage for up to 18 months after coverage as an insured employee ends. For terminations on or after May1, 2013.
HCSA COBRA Notice and Election Form
- 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
- 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
- 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 before April 30, 2013.
GIC Dental/Vision COBRA Application
- 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 1,2013
This information provided by the Group Insurance Commission.
