Retired State Employee Forms

Breadcrumbs

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.
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
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.
Buy-Out

The health insurance buy-out option is now available twice per year.
HIPAA Privacy Forms
Retiree Dental Enrollment Form
Retiree Dental COBRA Form

Main Menu