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 and remarriage particularly, can be very costly to you, and you may be responsible for additional premiums or medical claims.

If you notice any errors on your benefit statement, fill out the Benefit Statement Change Form and send with the required documents, as applicable, to the GIC. For fraud prevention purposes, the Nomination of Beneficiaries forms are not available on the GIC’s website.  See your GIC Benefit Coordinator or call the GIC at (617) 727-2310 extension 1 or TDD/TTY (617) 227-8583 for the appropriate Nomination of Beneficiary form.

Benefit Statement Change Form 1 pdf format of benstatementchangeform1.pdf
– for active state employees and retired state employees

Benefit Statement Change Form 2 pdf format of benstatementchangeform2.pdf
– for Retired Municipal Teachers, Elderly Governmental Retirees, state survivors, and members on COBRA

Benefit Statement Change Form 3 pdf format of benstatementchangeform3.pdf
–for municipal employees, retirees and survivors 

This information provided by the Group Insurance Commission .