Return all initial enrollment forms, along with required documentation, to your municipal benefits office.

Required Documentation - a list of the documents you must provide, along with your enrollment application, to join the GIC.

Initial Enrollment Form for Active Employees and Non-Medicare Retirees/Survivors pdf format of initialmuniemployeenonmedicareform.pdf
- Use this form if you are an active employee or if you are a retiree and you and your covered dependents are not covered by Medicare. - For municipal enrollees joining July 1, 2015.

Initial Municipality Enrollment Form for Medicare Retirees and Survivors pdf format of initialmunimedicare.pdf
- Use this form if you and your covered dependents are covered by Medicare. - For municipal enrollees joining July 1, 2015.

Initial Over/Under Age 65 Medicare/Non-Medicare Combination Coverage Form doc format of Over Underenrollment Muni Form
- Use this form if one or more family members are on Medicare and the rest are not.  - For municipal enrollees joining July 1, 2015.

Dependent Ages 19 to 26 Enrollment/Change Form- If you wish to cover your dependent ages 19 to 26, complete and return this form along with the appropriate enrollment form and your dependent's birth certificate. Note: as outlined on the form, you must notify the GIC if your dependent's status changes after completion of this form. Please note: the address on the form is the GIC's; initial municipal enrollment forms should be returned to your benefits office, not the GIC.

Handicapped Dependent Application - To cover a handicapped dependent.

Municipal Retiree Dental Form pdf format of retiree_dental_muniform.pdf
- Town of Ashland Retirees and Survivors only - use this form to Enroll in the GIC Retirees Dental Plan Effective July 1, 2015.

CHIP Notice - This notice provides information on how to access premium assistance if you or your children are eligible for Medicaid or CHIP.

Marketplace notice - This notice provides some basic information concerning your current health insurance coverage and the availability of other coverage.


This information provided by the Group Insurance Commission .