Enrollment/Change Form-1 (1MUN)
Use this form as a new hire, at Annual Enrollment, within 60 days of a documented qualifying status change, address and name changes, and for divorce and remarriage notifications.
- Basic Life and Health Insurance enrollment - Enroll in coverage as a new hire, during annual enrollment, or within 60 days of certain qualifying status changes.
- Change and Notification - Use this form to notify the GIC of a name change, address change, divorce, legal separation and remarriage.
- Add/Drop Dependents - Use this form to add or drop dependents as a new hire, during Annual Enrollment, or within 60 days of certain qualifying status events.
- Basic Life enrollment - only available as a new hire or during annual enrollment.
- Optional Life Insurance (Active employees) - Active State Employees may apply for optional life insurance or to change from non-automatic increase to automatic increase at any time. The GIC will notify the life insurance carrier of your application; the carrier will send you a medical application to complete and return. See your GIC Coordinator for a Life Insurance Beneficiary Form.
- Optional Life Insurance Smoker Status: At initial enrollment or 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.
- Long Term Disability (LTD) (Active Employees) - Active State Employees may enroll as a new hire or apply for coverage at any time during the year. The GIC will notify the LTD carrier of your application; the carrier will send you a medical application to complete and return.
- Cancel Health Insurance Coverage: Use this form to cancel your Health Insurance coverage during Annual Enrollment or within 60 days of a documented qualifying event. Cancellation effective dates for qualifying events are determined by the GIC upon receipt of completed forms and documentation.
- Cancel Long Term Disability or Optional Life Insurance Coverage: Use this form to cancel your Long Term Disability or Optional Life Insurance coverage. LTD and Optional Life can be canceled throughout the year. Cancellation effective dates are determined by the GIC upon receipt of completed form.
DEPENDENT AGE 19 TO 26 ENROLLMENT/CHANGE FORM
Use this form to enroll your dependent age 19 to 26 for the first time or to report your dependent’s age 19 to 26 status change. Upon receipt of a complete application, the GIC will determine coverage eligibility and effective date. For new insureds, coverage for the dependent age 19 to 26 will begin on the new insured’s effective date. Dependents of existing GIC enrollees who are already over age 19 must have a qualifying event to enroll during the year or may apply during the GIC’s Annual Enrollment. Incomplete applications will be returned. PLEASE USE ONE FORM FOR EACH DEPENDENT AGE 19 TO 26.
HIRD Disclosure Form
You are completing this form because you have declined to participate in your employer sponsored health insurance plan and/or have declined to participate in the employer’s “Section 125 Cafeteria Plan” pre-tax purchasing arrangement. A Section 125 Plan is not health insurance; it is a way to purchase health insurance
on a pre-tax basis. For information about affordable health insurance options, visit the Commonwealth Connector at www.mahealthconnector.org .