• Hand filling out a form.
  • Retiree/Survivor Enrollment/Change Form-RS

    This form is for state and municipal retirees and survivors.  Use this form to enroll in GIC health insurance coverage for the first time at retirement, during Annual Enrollment, for an address or name change, within 60 days of a documented qualifying status change, and if you are a new municipal survivor applying for coverage for the first time. During Annual Enrollment and within 60 days of a qualifying status change, you can also use this form to cancel coverage, and add or drop your spouse or dependent(s).

    Other forms in this section include the required Medicare Part D Opt-in form if you are enrolling for the first time in one of the following GIC Medicare plans: Harvard Pilgrim Medicare Enhance, Health New England MedPlus or UniCare State Indemnity Plan Medicare Extension (OME).  If you are dis-enrolling from Fallon Senior Plan or Tufts Medicare Preferred, or are canceling your GIC Medicare coverage, you must fill out the Medicare Advantage/EGWP dis-enrollment form found on this page.

  • Employment Status Change Form-1A

    Use this form when you have an employment status change including retiring from state service, terminating state service, starting or returning from a leave of absence, and transferring to or from your agency. State Retirees can use this form to change their Optional Life Insurance election amount and to cancel 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, change or cancel Retiree Dental coverage during Annual Enrollment, or within 60 days of a qualifying status change.

  • Buy-Out

    If you have access to non-GIC health insurance, for example, through a spouse, it may pay to participate in the buy-out program. The health insurance buy-out option is available twice per year.

  • Dependent Ages 19 to 26 Enrollment/Change Form

    Use this form to add your dependent age 19 to 26 to your coverage as a new employee, during Annual Enrollment, or to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area or when he/she no longer is a full-time student.

  • 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.

  • Smoker Status Change Form-1 for Retirees

    During Annual Enrollment if you have been tobacco-free for at least the past 12 months, use this form to change your smoker status.

  • 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.

  • Third Party Address Request

    Use this form to set up an address in the GIC’s system that’s different than the insured’s address.  Common requests of this nature are for a divorce/separated spouse, a dependent under age 19 who does not reside with the insured, and for a dependent age 19-26 who lives outside of the service area.

  • HIPAA Privacy Forms

  • GIC Logo