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.

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).

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, 2017.

Initial Enrollment Form for Retirees and Survivors  – use this form if you are a retiree or survivor and are from a municipality joining the GIC July 1, 2017.

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.

Municipal Retiree Dental Enrollment/Change 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 (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. 

Benefit Statement Change Form - Use this form to update the GIC on the information included on your personalized benefit statements mailed in January.  Failure to notify the GIC of family status changes, such as legal separation, divorce, remarriage, and /or addition of dependents can result in financial liability to you.

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.

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 - 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 - 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.

Newsletter Quantity Change Form - Use this form to reduce the number of printed newsletters your agency/municipality receives.

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