Insurance Enrollment and Change Form (Form 1) - For state, housing authority, redevelopment authority, (employees and retirees) and planning council enrollees enrolling in, changing coverage and/or canceling coverage for:
- Basic Life and Health Insurance enrollment - Note: you may only enroll in coverage as a new hire or during annual enrollment, unless you move out of your plan's service area or can provide proof of involuntary loss of coverage elsewhere.
- 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.
- 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/Change GIC Coverage - Use the form to notify the GIC of a name change, address change, leave of absence, return to payroll, retirement, agency transfer, and termination of state service.
Insurance Data Form (IDF) - Use this form to add, change, and delete a spouse and/or dependent. Must attach required documentation, as listed on the form.
This information provided by the Group Insurance Commission.