Active State Employee Forms

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

List of GIC Benefit Coordinators

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 Ages 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.

Buy-Out for State Employees and Retirees - If you have access to non-GIC Health Insurance (for example, through your spouse) it may pay to participate in the Buy-out Program.

Dental & Vision 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 (Notice of Exchange Options) - 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.

Premium Assistance Notice (CHIP) - 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 - 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.

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

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

Benefit Statement Change Form - Use this form to get your GIC records up-to-date.  Failure to report changes to your marital status particularly can be very costly to you, as you may be responsible for additional premiums or medical claims.

Handicapped Dependent Form - 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 Benefit 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.

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