• Hand filling out a form.
  • Municipal Enrollment/Change Form-1MUN

    This form (Form-1MUN) is for enrolling in or changing your election of health insurance. Use this form as a new hire, at Annual Enrollment, within 60 days of a documented qualifying status change, name and address changes, 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.

  • Municipal Employment Status Change Form-1AMUN

    This form is for when you have an employment status change including transferring to or from your municipality, terminating municipal employment, and at retirement.

  • Retiree/Survivor Enrollment/Change Form-RS

    This form is for state and municipal retirees and survivors.  Use this form to enroll in GIC health insurance coverage for the first time at retirement, during Annual Enrollment, for an address or name change, within 60 days of a documented qualifying status change, and if you are a new municipal survivor applying for coverage for the first time. During Annual Enrollment and within 60 days of a qualifying status change, you can also use this form to cancel coverage, and add or drop your spouse or dependent(s).

    Other forms in this section include the required Medicare Part D Opt-in form if you are enrolling for the first time in one of the following GIC Medicare plans: Harvard Pilgrim Medicare Enhance, Health New England MedPlus or UniCare State Indemnity Plan Medicare Extension (OME).  If you are dis-enrolling from Fallon Senior Plan or Tufts Medicare Preferred, or are canceling your GIC Medicare coverage, you must fill out the Medicare Advantage/EGWP dis-enrollment form found on this page.

  • 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.

  • Municipal Retiree Dental Enrollment/Change Form

    Retiree Dental Enrollment form for retirees and survivors from municipalities that offer the GIC Retiree Dental 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. 

  • Benefit Statement Change Form

    Use this form to update the GIC on the information included on your personalized benefit statements mailed in January.  Failure to notify the GIC of family status changes, such as legal separation, divorce, remarriage, and /or addition of dependents can result in financial liability to you.

  • Employee Acknowledgement Form

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

  • 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 - Municipal Employees

    If you are a municipal employee with health coverage through the GIC, 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.
  • Retiree Dental COBRA Form

    Dependents, including a former spouse, who lose retiree dental coverage, may continue retiree dental coverage for up to 36 months through the COBRA provision.

  • 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.

  • HIPAA Privacy Forms

    These forms help protect GIC insureds’ and dependents’ protected health information.  The Notice of GIC Privacy Practices available here is also included in the handbook sent to you by your health plan and will be mailed to you in the event your coverage is terminated.

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