Retired State Employee 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.

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 Medicare Advantage/EGWP dis-enrollment form found on this page.

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 - 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.

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. 

Buy-Out - If you have access to non-GIC health insurance, for example, through a spouse, it may pay to participate in the buy-out program. The health insurance buy-out option is available twice per year. To take advantage of the health insurance buy-out, send the completed Buy-out form to the GIC no later than November 3, 2017 for the January 1, 2018 buy-out.  Forms received after the deadline will not be accepted.

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.

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.

Smoker Status Change Form-1 for Retirees - 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 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.

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 - 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.

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