• Hand filling out a form.
  • Medicare Plan Change Form

    To change your plan selection, during Annual Enrollment, if both you and your covered spouse, if applicable, are enrolled in a GIC Medicare Plans.

  • Insurance Enrollment/Change and Spouse/Dependent Forms

    For new State hires and for State employees and Non-Medicare retirees and survivors changing coverage and/or canceling coverage.
  • 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.

  • Retiree Dental Enrollment Form

    Form to enroll in the Retiree Dental Program.

  • Buy-Out

    The health insurance buy-out option is available twice per year.
  • Dependent Ages 19 to 26 Enrollment Application

    You may apply for coverage for your dependent ages 19 to 26 as a new employee, when he/she turns age 19, during the GIC's Annual Enrollment period, or with proof of loss of other health insurance coverage.
  • Handicapped Dependent Form

    Form to cover a dependent who became mentally or physically incapable of earning his/her own living prior to age 19; or became permanently and totally disabled and became so on or after age 19 and is under age 26.

  • Life Insurance Beneficiary Forms

    These forms are used to designate your beneficiary or beneficiaries in the event of your death.
  • 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.

  • HIPAA Privacy Forms

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