GIC Print Forms

These forms are intended for use by GIC members who choose to print and mail forms. Forms should be completed and submitted during GIC's Annual Enrollment or within 60 days of a qualifying event.

GIC members with an up-to-date email address on GIC records received a registration email, have access to MyGICLink, and can view benefits throughout the year and update coverage during Annual Enrollment or if experiencing a qualifying event.

If you haven’t received a MyGICLink registration email, please complete the email update form. You will receive an email to register for the GIC member benefits portal as soon as GIC has updated your email.

State Employee Forms

• State Employee Enrollment/Change (FORM 1)

Health, basic life, optional life, and long-term disability insurance.

• Employment Status Change (FORM 1A)

Leave of Absence, Transfers and Termination, Retirement

• Dental/Vision Enrollment/Change (FORM 1DV)

The Dental/Vision Plan is for managers, Legislators, Legislative staff, and certain Executive Office and MBTA staff only.

• Health Care Spending Account (HCSA)

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

• Dependent Care Assistance Program (DCAP)

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

• Pre-tax to Post-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 If your deductions are now taken on a pre-tax basis, you may elect to have them taxed effective July 1.

• State Employee Acknowledgement (for GIC Coordinators)

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

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• Benefit Statement Correction
• Beneficiary

Note: The beneficiary form can only be submitted via GIC Online Forms

• COBRA
• Disabled Dependent

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.

• HIPAA Privacy

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

Note: This form can only be requested through the GIC Online Contact Form. All employees and non-Medicare retirees and survivors who have GIC health insurance coverage receive a 1095-B form each year.

• 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.

• Health Insurance Buy-Out

Buy out GIC health insurance if you have proof of alternate coverage beginning in the new Fiscal Year. (Note: Applications are only available during Annual Enrollment and the Fall Buy-out period).

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State Retiree Forms

• State Retiree & Survivor Health Insurance Enrollment/Change (FORM RS)
• Employment Status Change (FORM 1A)
• Retiree Dental Enrollment/Change (FORM RD) 
• 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.

• Tufts Medicare Preferred Disenrollment Form

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• Benefit Statement Correction
• Beneficiary

Note: The beneficiary form can only be submitted via GIC Online Forms

• COBRA
• Disabled Dependent

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.

• HIPAA Privacy

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

Note: This form can only be requested through the GIC Online Contact Form. All employees and non-Medicare retirees and survivors who have GIC health insurance coverage receive a 1095-B form each year.

• 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.

• Health Insurance Buy-Out

Buy out GIC health insurance if you have proof of alternate coverage beginning in the new Fiscal Year. (Note: Applications are only available during Annual Enrollment and the Fall Buy-out period).

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Municipal Employee & Retiree Forms

Please ensure eligibility before completing the following forms: list of participating municipalities

• Municipal Retiree & Survivor Health Insurance Enrollment/Change (FORM RS)
• Municipal Employee Health Insurance Enrollment/Change (FORM 1MUN)
• Municipal Employment Status Change (FORM 1AMUN)

Transfers, Termination, and Retirement

• Municipal Retiree & Survivor Dental Enrollment/Change (FORM MRD)

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

• Tufts Medicare Preferred Disenrollment Form

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• Municipal Employee Acknowledgement (for GIC Coordinators)
• Benefit Statement Correction
• COBRA
• Disabled Dependent

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.

• HIPAA Privacy

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

Note: This form can only be requested through the GIC Online Contact Form. All employees and non-Medicare retirees and survivors who have GIC health insurance coverage receive a 1095-B form each year.

• 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.

Retired Municipal Teacher (RMT)

Please ensure eligibility before completing the following forms: list of participating RMT municipalities

• Retired Municipal Teacher Life & Health Insurance Enrollment (FORM RMT)
• RMT Dental Enrollment/Change (FORM RD) 

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• Benefit Statement Correction
• Beneficiary

Note: The beneficiary form can only be submitted via GIC Online Forms

• COBRA
• Disabled Dependent

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.

• HIPAA Privacy

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

Note: This form can only be requested through the GIC Online Contact Form. All employees and non-Medicare retirees and survivors who have GIC health insurance coverage receive a 1095-B form each year.

• 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.

• Health Insurance Buy-Out

Buy out GIC health insurance if you have proof of alternate coverage beginning in the new Fiscal Year. (Note: Applications are only available during Annual Enrollment and the Fall Buy-out period).

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Resources

• 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 Coordinator List

Find someone from your benefits office to assist you with your selection of GIC benefits.

• 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.