New Hire and Annual Enrollment Forms

Items marked as require Acrobat Reader
Active Employees - Forms are also available through your GIC Coordinator/Benefits Office and at the Health Fairs
Retirees and Survivors - Forms are also available through the GIC and at the Health Fairs

Active Employees - complete and return forms to your GIC Coordinator/Benefits Office.
Current Retirees and Survivors complete and return Enrollment/Change and IDF forms to the GIC. If you are a new municipal retiree/survivor or a RMT (Retired Teacher) converting to municipal coverage, return completed forms to your municipal benefits office.

Insurance Enrollment/Change and Spouse/Dependent Forms

Insurance Enrollment and Change Form (Form 1) - For state enrollees, housing authority and planning council enrollees enrolling in, changing coverage and/or canceling coverage for:

• Basic Life and Health Insurance enrollment (also complete HMO application, only needed if NHP Care selected) - 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 loss of coverage elsewhere.
  
• Basic Life enrollment - only available as a new hire or during annual enrollment
  
• Optional Life Insurance (Active 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 Beneficiary Form.
  
• Long Term Disability (LTD) for Active Employees - 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/Change GIC Coverage -- Name Change, Address Change, Leave of Absence, Return to Payroll, Retirement, Agency Transfer, Termination of State Service

Health Insurance Responsibility Disclosure (HIRD) form for HR/CMS Agencies and UMASS - for GIC-eligible employees who do not elect GIC coverage and for non-GIC eligible employees who do not elect to pay for health insurance through the Commonwealth-sponsored Section 125 Plan.

Health Insurance Responsibility Disclosure (HIRD) form for Offline Agencies - for GIC-eligible employees who do not elect GIC coverage and for non-GIC eligible employees who do not elect to pay for health insurance through your Section 125 Plan.

Insurance Data Form (IDF) - For adding, changing, and deleting a spouse and/or dependent.

Forms for Participating Municipal Employees and Retirees

Initial Municipality Enrollment Form for Employees and Non-Medicare Retirees and Survivors - (also complete HMO application, only needed if NHP Care selected) - For municipal enrollees joining July 1, 2008 and Non-Medicare Retired Teachers from Gill Montague, Holbrook, Millis and Winthrop converting to municipal coverage.

Initial Municipality Enrollment Form for Medicare Retirees and Survivors - For municipal enrollees joining July 1, 2008 and Medicare Retired Teachers from Gill Montague, Holbrook, Millis and Winthrop converting to municipal coverage.

Initial Under/Over 65 Non-Medicare/Medicare combination enrollment form - for municipal enrollees joining July 1, 2008.

Enrollment and Change Form (Form 1) - For City of Springfield and Town of Saugus enrollees enrolling, changing coverage and/or cancelling coverage. NOTE: This form is only for City of Springfield and Town of Saugus enrollees - state enrollees must use the GIC's Form-1 above.

Insurance Data Form (IDF) - For adding, changing, and deleting a spouse and/or dependent.

Health Insurance Responsibility Disclosure (HIRD) form for Municalities - for GIC-eligible employees who do not elect GIC coverage and for non-GIC eligible employees who do not elect to pay for health insurance through your Section 125 Plan.

Employee Acknowlegement Form

Employee Acknowlegement Form (State) - All new hires and employees who elect GIC coverage for the first time must complete this form verifying that you have familiarized yourself with your benefit options. This form is retained in your personnel file.

Employee Acknowledgement Form (Municipalities) - All new hires and employees who elect GIC coverage for the first time must complete this form verifying that you have familiarized yourself with your benefit options. This form is retained in your personnel file.

HMO Enrollment Applications

HMO Applications: Effective July 1, 2008, simply use the GIC Enrollment Form-1 or the appropriate municipal enrollment form to enroll in or change your health plan selection - UNLESS you are enrolling in NHP Care (application below). Existing retirees/survivors must write to the GIC to request a change. If you are a Medicare Retiree/Survivor, and are enrolling in a GIC Medicare HMO, the Plan will contact you with their enrollment form after the GIC has notified them of your enrollment.

NHP Care

COBRA Notice

Dental/Vision

GIC Dental/Vision Enrollment and Change Form (Form-1) for managers, Legislators, Legislative staff and Executive Office staff only. This Plan is only available to employees not covered by collective bargaining who do not have another Dental and/or Vision Plan. Employees of authorities, higher education, and the Judicial Trial Court System are not eligible for this Plan. During annual enrollment, eligible employees may enroll in the plan or change their dental plan type.

GIC Retiree Dental Plan Enrollment Application - Retirees, Retired Municipal Teachers (Non-City of Springfield RMTs), Elderly Governmental Retirees (EGRs), and survivors may join during annual enrollment, when COBRA dental coverage ends, or at retirement. However, if you drop coverage after joining, you never can enroll again in the Plan. See the Retiree Dental section for details.

Retiree Discount Vision Plan - No enrollment form necessary - see Retiree Vision section for details.

Buy-Out and Pre-Tax Applications

Buy-Out Application - If you were insured with the GIC on January 1, 2008 or before and continue your coverage through June 30, 2008, you may buy out your health plan coverage during annual enrollment.  You must have other non-state health insurance coverage that is comparable to the health insurance you now receive through the Group Insurance Commission.

Under the buy-out plan, eligible enrollees receive 25% of the full cost monthly premium in lieu of health insurance benefits for one 12-month period. The amount of payment depends on your health plan and coverage. Buy-Out Questions? Contact the GIC 617.727.2310, ext. 1.

Employee and State Retiree Buy-Out Rates
Retired Municipal Teacher (RMT) and Elderly Governmental Retiree (EGR) Buy-Out Rates

Pre-Tax Basic Life and Health Insurance Plan Election Not to Participate Form - The Commonwealth deducts the employee's share of basic life and health insurance premiums on a pre-tax basis, unless an employee opts out of this option. By deducting on a pre-tax basis, the net result is a slight increase in your paycheck. During annual enrollment, or when you have a qualifying event, you have the opportunity to change the tax status of your premiums. If your deductions are now taken on a pre-tax basis, you may elect to have them taxed effective July 1. If you previously chose not to take the pre-tax option, you may switch to a pre-tax basis effective July 1.

To opt out of pre-tax deductions, complete the Pre-tax Basic Life and Health Insurance Plan Election Not to Participate Form and give it to your Payroll Coordinator. If you previously elected NOT to participate in Pre-tax deductions, see your Payroll Coodinator to elect pre-tax deductions. There are no forms to complete. Qualifying events to elect in or out of pre-tax deductions must comply with Federal IRS regulations and definitions. These include: marriage or divorce, birth or adoption of a child, death of spouse or dependent, spouse commences or is terminated from employment, employee or spouse takes unpaid leave of absence, or employee involuntarily loses health insurance coverage through no fault of his/her own. For Pretax questions, contact your payroll department.