Use this form to add your dependent ages 19 to 26 as a new employee, during the GIC’s Annual Enrollment, in the event of a Qualifying Status Change, when your dependent changes to a full-time student living outside of the plan's service area or is no longer a full-time student.

For other dependent changes, use the Enrollment/Change Form (State Employees and Offline Agency Employees) – or the Municipal Enrollment/Change Form (Municipal Employees).

Please keep in mind the following:

  • The insured must have family plan coverage.
  • The GIC will determine eligibility and effective dates.

You MUST notify the GIC when your dependent age 19 to 26 is no longer a full-time student or has moved out of the health plan’s service area.

Dependent Ages 19 to 26 Enrollment/Change Form docx format of Dependent Ages 19 to 26 Application

This information provided by the Group Insurance Commission .