• Hand filling out a form.
  • Municipal Insurance Enrollment/Change and Spouse/Dependent Forms

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

  • Medicare Plan Change Form

    If you are an existing state or municipal retiree or survivor already enrolled in a GIC Medicare plan, use this form to change your plan election during Annual Enrollment.  In order to use this form, both you and your covered spouse, if applicable, must already be enrolled in a GIC Medicare plan.

  • Dependent Ages 19 to 26 Enrollment Application

    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.
  • Municipal Retiree Dental 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

  • 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.

  • Leaving Municipal Service Forms

    Forms to complete when  leaving municipal service.

  • 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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