Existing Municipality Forms

For Municipal Employees and Non-Medicare Retirees and Survivors changing or canceling coverage.

You may apply for coverage for your dependent ages 19 to 26 as a new employee, during the GIC's Annual Enrollment period, or with proof of loss of other health insurance coverage.

for GIC-eligible employees who do not elect GIC coverage and for non-GIC eligible employees who do not elect to pay for health insurance through a Commonwealth, offline agency or municipality-sponsored Section 125 Plan

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

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.

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.