Updated April 13, 2015


New employees must make their health benefit elections within ten (10) calendar days of the employee’s first days of employment.  You, as the GIC Coordinator, have 21 days to forward forms to the GIC.  To select their benefits, employees must complete the following forms completely and legibly:

  • Municipal Enrollment/Change Form (Form-1MUN)
    • For spousal coverage – copy of marriage certificate. 
    • For former spouse – provide following sections of the legal separation or divorce decree: page with absolute date, health insurance language, signature pages, and former spouse’s address
    • For dependent coverage under age 19 – copy of birth certificate(s) – the birth certificate must show the parent-child relationship to the insured or his/her spouse
    • For dependent coverage age 19 or over – Dependent Age 19 to 26 Enrollment/Change Form and a copy of birth certificate.  For handicapped dependent coverage, a Handicapped Dependent Application and a copy of birth certificate.  Birth certificates must show parent-child relationship to the insured or his/her spouse.
  • Employee Acknowledgement form
  • Marketplace Notice
  • Premium Assistance Notice (CHIP)

All new employees should automatically be enrolled in pre-tax health insurance deductions unless they opt out of participating. This is known as a Section 125 Plan. If the employee elects to opt out, he/she must complete the Pre-Tax Basic Life and Health Insurance Plan Election Not to Participate Form.

After the plan election is made, complete the following:

  1. Verify that the forms are completed accurately and completely. Ensure that the employee has checked the information entered on his/her forms, and has signed and dated all forms.
  2. On the Municipal Enrollment/Change Form (Form-1MUN), indicate the agency/division number and the date entered municipal service.
  3. Photocopy completed GIC forms and file them in the employee’s personnel file. 
  4. Give the employee a copy of the Employee Acknowledgement form and file the original in the employee’s personnel file.  Do not send this form to the GIC.
  5. Send all other original signed forms to the GIC.
  6. Update your payroll system with the new premium deductions.


If declining health benefits:

  1. Employee completes and signs the Municipal Enrollment/Change Form (Form-1MUN), checking the decline GIC health insurance coverage box.  This form is necessary to document that the employee was offered GIC health insurance coverage in accordance with health care reform requirements.
  2. Retain completed Municipal Enrollment/Change Form (Form-1MUN) and file in the employee’s personnel file.  Do not send the form to the GIC.


If a new employee, or his/her covered dependent has no health coverage and incurs unplanned and urgent medical expenses during his/her new hire waiting period, he/she may apply to buy GIC health coverage at the full cost premium for that period of time (60 or more days, depending on the date of hire). The total claims expenditure must exceed the full cost premium for the hiatus period. New employees who begin employment on the 16th day of a month or later will not be charged premium for that month; new employees who begin employment on or before the 15th day of a month shall be charged the full premium cost for the month. To apply for retroactive health insurance, the employee must write to the GIC's Director of Operations to request the coverage. If approved, coverage shall become effective as of the employee's first day of active employment, subject to his or her timely payment of the full cost health insurance premium for the entire hiatus period.

  1. Provide to the employee a copy of his/her new hire Municipal Enrollment/Change Form (Form-1MUN).
  2. Instruct the employee to include the following information in their request to the GIC:
    • Employee's name
    • Employee's Social Security Number
    • Photocopy of new hire Municipal Enrollment/Change Form (Form-1MUN)
    • Dates of health care expenses
    • Photocopies of all incurred health care claims
    • Statement from the employee that he/she understand that he/she is responsible to pay the full cost premium for the entire new hire hiatus period
  3. The GIC will notify the employee of the approval or denial of the application and, if approved, will bill the employee for the full cost premium owed.

This information provided by the Group Insurance Commission .