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

    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.

  • 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 to enroll in GIC health insurance coverage for the first time at retirement, for Annual Enrollment and within 60 days of a documented qualifying status change, and for new municipal survivors applying for coverage for the first time.

  • 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.

  • 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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