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, within 60 days of a documented qualifying status change, address and name changes, and for divorce and remarriage notifications. Use this form to add or drop your spouse and dependent(s) from coverage during Annual Enrollment and within 60 days of a documented qualifying status change.

  • 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.
  • 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 a pipe, used snuff, chewing tobacco or a nicotine delivery system) for at least the past 12 months, use this form to change your smoker status.  Changes in smoking status made 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.
  • Cancel Health Insurance Coverage: Use this form to cancel your Health Insurance coverage during Annual Enrollment or within 60 days of a documented qualifying event.  Cancellation effective dates for qualifying events are determined by the GIC upon receipt of completed forms and documentation.
  • Cancel Long Term Disability or Optional Life Insurance Coverage: Use this form to cancel your Long Term Disability or Optional Life Insurance coverage.  LTD and Optional Life can be canceled throughout the year. Cancellation effective dates are determined by the GIC upon receipt of completed form.

This information provided by the Group Insurance Commission .