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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

Enrollment/Change Form 1 - This form (Form-1) 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, and for divorce and remarriage notifications. Use this form to add or drop your spouse and dependent(s) from coverage during Annual Enrollment and within 60 days of a documented qualifying status change.

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, and transferring to or from your agency. State Retirees can use this form to change their Optional Life Insurance election amount and to cancel coverage.

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, or to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area or 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.

GIC Dental/Vision Enrollment/Change Form - Form to enroll in GIC Dental/Vision coverage. Use this form  to enroll in coverage as a new hire, for Annual Enrollment, within 60 days of a documented qualifying status change, and for address and name changes.  This form is also for adding and cancelling spouse and dependent coverage during Annual Enrollment and within 60 days of a qualifying status change.

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.

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.

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.

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.

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. 

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 (Industrial Accident, Employee's personal illness, or Maternity), may apply to continue part-cost premiums by completing the Leave of Absence Form (Form-11). The employee, Agency Head and physician must complete all sections before the application can be considered.

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

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.

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.

These forms are used to designate your beneficiary or beneficiaries in the event of your death:

Nomination of Beneficiaries Form 319 – This form is used to designate up to three GIC life insurance beneficiaries.

Nomination of Beneficiaries Form G-500 – This form is used to designate four or more beneficiaries and trusts for GIC life insurance benefits.

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 extension 1 or TDD/TTY (617) 227-8583 to have  the appropriate Nomination of Beneficiary form mailed to you.

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.

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. These include: 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.

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.

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.

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, and if you are a new municipal survivor applying for coverage for the first time. During Annual Enrollment and within 60 days of a qualifying status change, you can also use this form to cancel coverage, and add or drop your spouse or dependent(s).

If you are dis-enrolling from Fallon Senior Plan or 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, and transferring to or from your agency. State Retirees can use this form to change their Optional Life Insurance election amount and to cancel coverage.

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. 

GIC Retiree Dental Enrollment/Change Form - All State Retirees, Survivors, GIC Retired Municipal Teachers (Non-participating municipal) and Elderly Governmental Retirees (EGRs) may join, change or cancel coverage during annual enrollment, or within 60 days of a qualifying status change. However, if you drop coverage after joining, you never can enroll again 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, or to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area or 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.

These forms are used to designate your beneficiary or beneficiaries in the event of your death:

Nomination of Beneficiaries Form 319 – This form is used to designate up to three GIC life insurance beneficiaries.

Nomination of Beneficiaries Form G-500 – This form is used to designate four or more beneficiaries and trusts for GIC life insurance benefits.

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 extension 1 or TDD/TTY (617) 227-8583 to have  the appropriate Nomination of Beneficiary form mailed to you.

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.

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.

Municipal Enrollment/Change (Form-1MUN) - This form (Form-1MUN) 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 notifications. Use this form to add or drop your spouse and dependent(s) from coverage during Annual Enrollment and within 60 days of a documented qualifying status change.

Municipal Employment Status Change (Form-1AMUN) - This form is for when you have an employment status change including transferring to or from your municipality, terminating municipal employment, and at retirement.

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, and if you are a new municipal survivor applying for coverage for the first time. During Annual Enrollment and within 60 days of a qualifying status change, you can also use this form to cancel coverage, and add or drop your spouse or dependent(s).

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, 2018.

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, or to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area or 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.

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 the spring GIC Annual Enrollment period, during the Open Enrollment for Municipalities joining Retiree Dental for the first time, or within 60 days of a qualifying status change.  However, if you drop coverage after joining, you never can enroll again in the Plan.

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.

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.

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

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.

COBRA Forms - Municipal Employees - 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.

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.

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.  If your school district is not listed, contact your local benefit office for your district's benefit options and forms:

Amesbury, Barnstable, Billerica, Blackstone Valley Regional SD, Braintree, Bridgewater, Bourne, Dedham, Dennis, Eastham, Everett, Granby, Greater Lawrence Regional SD, Narragansett Regional SD, Harvard, Holyoke, Hudson, Martha's Vineyard Regional SD, Milton, Montague, Newbury, North Adams, North Attleboro, N. Middlesex Regional SD, Norwell, Paxton, Pioneer Valley Regional SD, Plainville, Quabbin Regional SD, Rehoboth, Revere, Rockland, Rockport, Rutland, Salisbury, Shawsheen Valley Regional SD, Spencer, Stoughton, Upper Cape Cod Regional SD, Wareham, Westfield, West Bridgewater, West Springfield, Whitman-Hanson SD, Wilbraham, Woburn

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.

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

Dependent Age 19 to 26 Enrollment Change Form FY19 - Use this form to add your dependent age 19 to 26 to your coverage as a new employee, during Annual Enrollment, or to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area or 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.

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

Beneficiary Forms - contact the GIC.

If you and/or your spouse are age 65 or over, learn more about Medicare and your GIC benefits for helpful information.

GIC Retiree Dental Enrollment/Change Form - All State Retirees, Survivors, GIC Retired Municipal Teachers (Non-participating municipal) and Elderly Governmental Retirees (EGRs) may join, change or cancel coverage during annual enrollment, or within 60 days of a qualifying status change. However, if you drop coverage after joining, you never can enroll again in the Plan. 

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.

GIC Retired Municipal Teachers - Learn more about GIC Retired Municipal Teachers (RMTs) and eligibility and coverage options here.

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.

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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