Return completed forms and required documentation to your benefits office - Do not send to the GIC.
Required Documentation - A listing of documents that must accompany your GIC application for coverage.
Initial Enrollment Form - To enroll in basic life and health coverage, Long Term Disability, and/or Optional Life Insurance.
Insurance Data Form - to add your spouse and/or dependents to your coverage.
Life Insurance Beneficiary Form - only available through your GIC Benefits Coordinator.
Dependent Ages 19 to 26 Application - If you wish to cover your dependent ages 19-26, complete and return this form with the Insurance Data Form and dependent's birth certificate.
Handicapped Dependent Form To cover a handicapped dependent.
CHIP Notice - This notice provides information on how to access premium assistance if you or your children are eligible for Medicaid or CHIP.
Dental/Vision Enrollment form - for managers not covered by collective bargaining. The plan primarily covers managers, Legislators, Legislative staff, and certain Executive Office and MBTA staff. Employees of authorities, municipalities, higher education, and the Judicial Trial Court system are not eligible for GIC Dental/Vision coverage.
Leave of Absence form - Employees who are taking an approved leave of absence without pay due to Industrial Accident, the employee's personal illness, or maternity may apply to continue coverage at the part cost premium.
This information provided by the Group Insurance Commission .