Use this form to add your dependent ages 19 to 26 as a new employee, during the GIC’s Annual Enrollment, or with proof of loss of other health coverage.  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.

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 doc format of Dependent Ages 19 to 26 Application

This information provided by the Group Insurance Commission .

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