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 and remarriage particularly, can be very costly to you, and you may be responsible for additional premiums or medical claims.

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 benstatementchangeform1.pdf
– for active state employees

Benefit Statement Change Form 2 pdf format of benstatementchangeform2.pdf
– for state retirees

Benefit Statement Change Form 3 pdf format of benstatementchangeform3.pdf
– for GIC Retired Municipal Teachers (RMTs)

Benefit Statement Change Form 4 pdf format of benstatementchangeform4.pdf
- for municipal enrollee, state survivors and members on COBRA


This information provided by the Group Insurance Commission .