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.

If you notice any errors on your benefit statement, fill out the Benefit Statement Change Form and send with the required documents, as applicable, to the GIC.

Benefit Statement Change Form 1 pdf format of change_form1.pdf
– for state employees and retirees

Benefit Statement Change Form 2 pdf format of change_form2.pdf
– for GIC Retired Municipal Teachers (RMTs), State Survivors and COBRA enrollees

Benefit Statement Change Form 3 pdf format of change_form3.pdf
– for municipal employees, retirees and COBRA enrollees


This information provided by the Group Insurance Commission .