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 elections.

  • 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.
  • 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.
  • Cancel Coverage: Use this form to cancel your Long Term Disability, Health Insurance or Optional Life Insurance coverage.
  • 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.

This information provided by the Group Insurance Commission .

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