Retired Municipal Teacher Forms

THESE FORMS ARE ONLY FOR BENEFITS VALID UNTIL JUNE 30, 2018.

If you wish to review the forms for benefits effective July 1, 2018, please see our FY19 forms page.

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

RMT Application - 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 - a list of the documents you must provide, along with your enrollment application, to join the GIC.

Retiree/Survivor Enrollment Change Form – use this form if you are already enrolled in GIC health insurance benefits and want to change your plan election during Annual Enrollment.  Depending on the plan you’re leaving and enrolling in, other forms may be required and are also on this page.

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

Beneficiary Forms - call the GIC.

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

Retiree Dental Enrollment 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 Ages 19 to 26 Enrollment Application - You may apply for coverage for your dependent ages 19 to 26 as a new employee, when he/she turns age 19, during the GIC's Annual Enrollment period, or with proof of loss of other health insurance coverage.

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.

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.

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.

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.

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