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GIC forms

Forms to enroll in, change, or cancel your GIC benefits. Please read the description in each form carefully. All forms are due to the GIC.

Table of Contents

Form

Active state employee forms

Ongoing enrollment and change forms for active state employees, for new hires, and for Annual Enrollment, and employment status changes.

GIC Coordinator List - find someone from your benefit office to assist you with your selection of GIC benefits.

Required Documentation for GIC Coverage - A list of the documents you must provide, along with your enrollment application, to join the GIC, to add a spouse or dependent, or when you are retired and you or your covered spouse become Medicare eligible. 

Enrollment/Change Form 1 - This form is for enrolling in, canceling, or changing your election of health, basic life, optional life, and long term disability insurance. Use this form:    

  • as a new hire
  • at Annual Enrollment
  • within 60 days of a documented qualifying status change
  • for an address or name change 
  • for divorce and remarriage notifications
  • to add or drop your spouse and dependent(s)

Employment Status Change Form 1A - Use this form when you have an employment status change including: 

  • retiring from state service 
  • terminating state service 
  • starting or returning from a leave of absence
  • transferring to or from an agency

GIC Dental/Vision Enrollment/Change Form - Use this form to enroll in coverage:

  • as a new hire
  • for Annual Enrollment
  • within 60 days of a documented qualifying status change
  • for address and name changes
  • adding and cancelling spouse and dependent coverage

The Dental/Vision Plan is for managers, Legislators, Legislative staff and certain Executive Office and MBTA 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, municipalities, and the Judicial Trial Court System are not eligible for this Plan. Keep in mind that once you choose a plan you may not change plans until the next annual enrollment, even if your dentist leaves the plan during the year.

Dependent Age 19 to 26 Enrollment Change Form - Use this form to add your dependent age 19 to 26 to your coverage:

  • as a new employee
  • during Annual Enrollment
  • to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area
  • when he/she no longer is a full-time student

The insured must have family plan coverage and 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.

Health Care Spending Account (HCSA) Forms - Enrollment and change and claim forms for the state employee Health Care Spending Account pre-tax program.

Dependent Care Assistance Program (DCAP) Forms - Enrollment, change and claim forms for the state employee Dependent Care Assistance (DCAP) pre-tax program.

Handicapped Dependent Application - Use this form to cover a dependent who became mentally or physically incapable of earning his/her own living prior to age 19; or became permanently and totally disabled and became so on or after age 19 and is under age 26.

Leave of Absence Form (Form 11) - Employees who are taking an approved leave of absence without pay due to one of the following three conditions may apply to continue part-cost premiums by completing the Leave of Absence Form (Form-11)  

  1. Industrial Accident
  2. Employee's personal illness or
  3. Maternity leave

The employee, Agency Head and physician must complete all sections before the application can be considered.

Pre-tax Application - The Commonwealth deducts the state 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 Coordinator 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, including:

  • marriage or divorce
  • birth or adoption of a child
  • death of spouse or dependent
  • spouse commences or is terminated from employment or
  • employee or spouse takes unpaid leave of absence

For Pretax questions, contact your payroll department.

State Employee Acknowledgement Form - New hires must complete this form to verify that they have been notified about their benefit options.

Third Party Address Request - Use this form to set up an address in the GIC’s system that’s different than the insured’s address.  Common requests of this nature are for a divorce/separated spouse, a dependent under age 19 who does not reside with the insured, and for a dependent age 19-26 who lives outside of the service area.

CHIP Notice - This notice provides information on how to access premium assistance if you or your children are eligible for Medicaid or CHIP.  If you or your children are eligible for Medicaid or the Children's Health Insurance Program (CHIP) and you are eligible for health coverage from the GIC, your state may have a premium assistance program that can help pay for coverage.  The CHIP notice provides information on how to access this assistance. See the form for contact information by state.

Marketplace Notice - This notice provides some basic information concerning your current health insurance coverage and the availability of other coverage. Note that most GIC-eligible employees are not eligible for tax credits toward Marketplace or Connector coverage. Those who are low income and face high premium costs (e.g., because they are low income and live out of state) might be eligible for tax credits toward Marketplace or Connector coverage; the Notice has this contact information. Agencies and Municipalities must give all new hires a copy of this notice.

COBRA Forms - If you are an employee of the Commonwealth of Massachusetts, you have the right to choose COBRA coverage if you lose your group health coverage because your hours of employment are reduced or your employment ends for reasons other than gross misconduct.

HIPAA Privacy Forms - These forms help protect GIC insureds’ and dependents’ protected health information. The Notice of GIC Privacy Practices available here is also included in the handbook sent to you by your health plan and will be mailed to you in the event your coverage is terminated.

1095-B Tax Form - All employees and non-Medicare retirees and survivors who have GIC health insurance coverage receive a 1095-B form each year. Here's what you need to know.

For fraud prevention purposes, the Nomination of Beneficiaries forms are not available on the GIC’s website.  See your GIC Coordinator for a form or call the GIC at (617) 727-2310 or TDD/TTY 711 to have  the appropriate Nomination of Beneficiary form mailed to you.

Municipality forms

Ongoing enrollment and change forms for participating municipal employees, retirees and survivors. Forms are for new hires, Annual Enrollment, and Employment status changes.

GIC Coordinator List - find someone from your benefit office to assist you with your selection of GIC benefits.

Required Documentation for GIC Coverage - A list of the documents you must provide, along with your enrollment application, to join the GIC, to add a spouse or dependent, or when you are retired and you or your covered spouse become Medicare eligible. 

Municipal Enrollment/Change (Form-1MUN) - This form is for enrolling in or changing your election of health insurance. Use this form:

  • as a new hire 
  • at Annual Enrollment
  • within 60 days of a documented qualifying status change, name and address changes
  • and for divorce and remarriage notification and
  • to add or drop your spouse and dependent(s) from coverage

Municipal Employment Status Change (Form-1AMUN) - This form is for when you have an employment status change including: 

  • transferring to or from a municipality
  • terminating municipal employment
  • retirement

Dependent Age 19 to 26 Enrollment Change Form - Use this form to add your dependent age 19 to 26 to your coverage:

  • as a new employee
  • during Annual Enrollment
  • to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area
  • when he/she no longer is a full-time student

The insured must have family plan coverage and 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.

Handicapped Dependent Application - Use this form to cover a dependent who became mentally or physically incapable of earning his/her own living prior to age 19; or became permanently and totally disabled and became so on or after age 19 and is under age 26.

Third Party Address Request form - Use this form to set up an address in the GIC’s system that’s different than the insured’s address.  Common requests of this nature are for a divorce/separated spouse, a dependent under age 19 who does not reside with the insured, and for a dependent age 19-26 who lives outside of the service area.

Municipal Employee Acknowledgement Form - New hires must complete this form to verify that they have been notified about their benefit options.

Municipal Initial Enrollment Form for Active employees – use this form if you are an active employee and are from a municipality joining the GIC July 1, 2018.

Municipal Initial Enrollment Form for retirees – use this form if you are a retiree or survivor and are from a municipality joining the GIC July 1, 2019.

GIC Retiree/Survivor Enrollment/Change Form - This form is for state and municipal retirees and survivors.  Use this form to enroll in GIC health insurance coverage:

  • for the first time at retirement
  • during Annual Enrollment
  • for an address or name change
  • within 60 days of a documented qualifying status change
  • if you are a new municipal survivor applying for coverage for the first time
  • to cancel coverage 
  • to add or drop your spouse or dependent(s)

If enrolling in coverage for the first time, you must also complete the Employment Status Change Form (Form 1AMUN for retiring municipal employees). State survivors wishing to pick up health insurance must go through the life insurance claims process and cannot use this form to apply for coverage. If you are dis-enrolling from Tufts Medicare Preferred, or are canceling your GIC Medicare coverage, you must fill out the EGWP Disenrollment Form.

Municipal Retiree Dental Form - Eligible retirees and survivors of the following participating municipalities may enroll, change or cancel coverage in Retiree Dental:

  • at retirement
  • during Annual Enrollment
  • during the Open Enrollment for Municipalities joining Retiree Dental for the first time
  • within 60 days of a qualifying status change

However, if you drop coverage after joining, you can never re-enroll in the Plan.

CHIP Notice - This notice provides information on how to access premium assistance if you or your children are eligible for Medicaid or CHIP.  If you or your children are eligible for Medicaid or the Children's Health Insurance Program (CHIP) and you are eligible for health coverage from the GIC, your state may have a premium assistance program that can help pay for coverage.  The CHIP notice provides information on how to access this assistance. See the form for contact information by state.

Marketplace Notice - This notice provides some basic information concerning your current health insurance coverage and the availability of other coverage. Note that most GIC-eligible employees are not eligible for tax credits toward Marketplace or Connector coverage. Those who are low income and face high premium costs (e.g., because they are low income and live out of state) might be eligible for tax credits toward Marketplace or Connector coverage; the Notice has this contact information. Agencies and Municipalities must give all new hires a copy of this notice.

COBRA Forms - If you are a municipal employee with health coverage through the GIC, you have the right to choose COBRA coverage if you lose your group health coverage because your hours of employment are reduced or your employment ends for reasons other than gross misconduct. Dependents, including a former spouse, who lose retiree dental coverage, may continue retiree dental coverage for up to 36 months through the COBRA provision.

HIPAA Privacy Forms - These forms help protect GIC insureds’ and dependents’ protected health information.  The Notice of GIC Privacy Practices available here is also included in the handbook sent to you by your health plan and will be mailed to you in the event your coverage is terminated.

1095-B Tax Form - All employees and non-Medicare retirees and survivors who have GIC health insurance coverage receive a 1095-B form each year. Here's what you need to know.

Retired municipal teacher forms

Forms for RMTs in the GIC RMT (non-municipal) Program.

GIC Retired Municipal Teachers (RMTs) Participating Towns/School Districts - According to Massachusetts Law Chapter 32B, the following city, towns and school districts participate in our Retired Municipal Teacher (RMT) benefit program. The GIC RMT program is different from the Participating Municipalities Program that joins GIC health insurance benefits under M.G.L. c. 32B, §§ 19 or 23.

Required Documentation for GIC Coverage - a list of the documents you must provide, along with your enrollment application, to join the GIC.

Retired Municipal Teacher Enrollment Form - use this form to enroll in GIC life and health coverage for the first time. NOTE: If your school district is not listed , you will not be approved for GIC coverage.

GIC Retiree Dental Enrollment/Change Form - Use this form to change or cancel coverage during Annual Enrollment or within 60 days of qualifying status change if you are a:

  • State retiree or survivor
  • GIC Retired Municipal Teachers from a non-participating municipality
  • Elderly governmental retirees (EGR)

However, if you drop coverage after joining, you can never re-enroll in the Plan. 

Dependent Age 19 to 26 Enrollment Change Form - Use this form to add your dependent age 19 to 26 to your coverage:

  • as a new employee
  • during Annual Enrollment
  • to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area
  • when he/she no longer is a full-time student

The insured must have family plan coverage and 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.

Handicapped Dependent Application - Form to cover a dependent who became mentally or physically incapable of earning his/her own living prior to age 19; or became permanently and totally disabled and became so on or after age 19 and is under age 26.

Third Party Address Request form - Use this form to set up an address in the GIC’s system that’s different than the insured’s address.  Common requests of this nature are for a divorce/separated spouse, a dependent under age 19 who does not reside with the insured, and for a dependent age 19-26 who lives outside of the service area.

Retired Municipal Teacher Notice – this notice provides an overview of your RMT options, enrollment, effective date, and answers to frequently asked questions.

HIPAA Privacy  Forms - These forms help protect GIC insureds’ and dependents’ protected health information.  The Notice of GIC Privacy Practices available here is also included in the handbook sent to you by your health plan and will be mailed to you in the event your coverage is terminated.

1095-B Tax Form - All employees and non-Medicare retirees and survivors who have GIC health insurance coverage receive a 1095-B form each year. Here's what you need to know.

For fraud prevention purposes, the Nomination of Beneficiaries forms are not available on the GIC’s website.  See your GIC Coordinator for a form or call the GIC at (617) 727-2310 or TDD/TTY 711 to have  the appropriate Nomination of Beneficiary form mailed to you.

Retired state employee forms

Ongoing enrollment and change forms for retired state employees and survivors as well as forms for Annual Enrollment and qualifying status changes.

Required Documentation for GIC Coverage - A list of the documents you must provide, along with your enrollment application, to join the GIC, to add a spouse or dependent, or when you are retired and you or your covered spouse become Medicare eligible. 

Retiree/Survivor Enrollment/Change Form-RS - This form is for state and municipal retirees and survivors.  Use this form to enroll in GIC health insurance coverage:

  • for the first time at retirement
  • during Annual Enrollment
  • for an address or name change
  • within 60 days of a documented qualifying status change
  • if you are a new municipal survivor applying for coverage for the first time
  • to cancel coverage 
  • to add or drop your spouse or dependent(s)

If enrolling in coverage for the first time, you must also complete the Employment Status Change Form (Form 1A for retiring state employees). State survivors wishing to pick up health insurance must go through the life insurance claims process and cannot use this form to apply for coverage. If you are dis-enrolling from Tufts Medicare Preferred, or are canceling your GIC Medicare coverage, you must fill out the EGWP Disenrollment Form.

Employment Status Change Form 1A - Use this form when you have an employment status change including: 

  • retiring from state service 
  • terminating state service 
  • starting or returning from a leave of absence
  • transferring to or from an agency 

State Retirees can use this form to change their Optional Life Insurance election amount and to cancel coverage.

GIC Retiree Dental Enrollment/Change Form - Use this form to change or cancel coverage during Annual Enrollment or within 60 days of qualifying status change if you are a:

  • State retiree or survivor
  • GIC Retired Municipal Teachers from a non-participating municipality
  • Elderly governmental retirees (EGR)

However, if you drop coverage after joining, you can never re-enroll in the Plan. 

Dependent Age 19 to 26 Enrollment Change Form - Use this form to add your dependent age 19 to 26 to your coverage:

  • as a new employee
  • during Annual Enrollment
  • to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area
  • when he/she no longer is a full-time student

The insured must have family plan coverage and 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.

Handicapped Dependent Application - Form to cover a dependent who became mentally or physically incapable of earning his/her own living prior to age 19; or became permanently and totally disabled and became so on or after age 19 and is under age 26.

Smoker Status Change Form 1 - This form is for State Retirees to change their smoker status during Annual Enrollment. If you have been tobacco-free  (have not smoked cigarettes, cigars or a pipe, used snuff, chewing tobacco or a nicotine delivery system) for at least the past 12 months, use this form to change your smoker status.  Changes in smoking status made during Annual Enrollment will become effective this following July 1.

Retiree Dental COBRA Form - Dependents, including a former spouse, who lose retiree dental coverage, may continue retiree dental coverage for up to 36 months through the COBRA provision.

Third Party Address Request form - Use this form to set up an address in the GIC’s system that’s different than the insured’s address.  Common requests of this nature are for a divorce/separated spouse, a dependent under age 19 who does not reside with the insured, and for a dependent age 19-26 who lives outside of the service area.

HIPAA Privacy Forms - These forms help protect GIC insureds’ and dependents’ protected health information.  The Notice of GIC Privacy Practices available here is also included in the handbook sent to you by your health plan and will be mailed to you in the event your coverage is terminated.

1095-B Tax Form - All employees and non-Medicare retirees and survivors who have GIC health insurance coverage receive a 1095-B form each year. Here's what you need to know.

For fraud prevention purposes, the Nomination of Beneficiaries forms are not available on the GIC’s website.  See your GIC Coordinator for a form or call the GIC at (617) 727-2310 or TDD/TTY 711 to have  the appropriate Nomination of Beneficiary form mailed to you.

Contact

Phone

Main Phone (617) 727-2310

M-F 8:45 a.m.-5 p.m.

TDD/TTY 711

Fax

Operations (617) 227-2681
Executive (617) 227-5181
Fiscal (617) 367-9874

Address

Street Address
19 Staniford St
Boston, MA 02114
Mailing Address
P.O. Box 8747
Boston, MA 02114
Image credits:  Shutterstock
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