Enrollment/Change Form pdf format of GIC Insurance Enrollment and Change Form
- This form (Form-1) is for enrolling in or changing your election of health, basic life, option life, and long term disability insurance.  Use this form as a new hire, at Annual Enrollment, or within 60 days of a documented qualifying status change to make your changes or elections.

  • Basic Life and Health Insurance enrollment - Enroll in coverage as a new hire, during annual enrollment, or within 60 days of certain qualifying status changes.
  • Change and Notification - Use this form to notify the GIC of a name change, address change, divorce, legal separation and remarriage.
  • Cancel Coverage: Use this form to cancel your Long Term Disability, Health Insurance or Optional Life Insurance coverage.
  • Add/Drop Dependents - Use this form to add or drop dependents as a new hire, during Annual Enrollment, or within 60 days of certain qualifying status events.
  • Basic Life enrollment - only available as a new hire or during annual enrollment.
  • Optional Life Insurance (Active employees) - Active State Employees may apply for optional life insurance or to change from non-automatic increase to automatic increase at any time. The GIC will notify the life insurance carrier of your application; the carrier will send you a medical application to complete and return. See your GIC Coordinator for a Life Insurance Beneficiary Form.
  • Optional Life Insurance Smoker Status: At initial enrollment or during Annual Enrollment, if you have been tobacco-free (have not smoked cigarettes, cigars or pipes nor used e-cigarettes, snuff or chewing tobacco) for at least the past 12 months, use this form to change your smoker status.  Changes in smoking status mad during Annual Enrollment will become effective this following July 1.
  • Long Term Disability (LTD) (Active Employees) - Active State Employees may enroll as a new hire or apply for coverage at any time during the year. The GIC will notify the LTD carrier of your application; the carrier will send you a medical application to complete and return.

This information provided by the Group Insurance Commission .