HomeMy Public PortalAboutGIC Enrollment FormGIC MUNICIPAL ENROLLMENT/CHANGE FORM (FORM-1MUN)
Health Insurance Commonwealth of Massachusetts
Group Insurance Commission
REQUIRED
INSURED
INFORMATION
Insured
Information
GIC-ID (usually Soc. Sec. #)
— —
Sex
❑ M ❑ F
Date of Birth
/ /
Dept. ID # or Agency/Division #
666 / 0314
Name — Last First MI
Address
Street
City
State
Zip
Contact
Information
Home or Cell Phone
( 1
Work Phone
( )
Email
Country (if not USA)
Employment
Information
Date of Hire (must be completed):
/ /
Name of Municipality:
TOWN OF WATERTOWN
REQUIRED FOR ALL NEW ENROLLMENTS
For Agency
Use Only
Does the employee participate in a public retirement system?
EYes alo
Check one:
❑❑Full-time ❑❑ Part-time
Number of work hours/week:
REQUIRED
Select all that apply:
❑❑ New Enrollment
Adding Dependent(s)
❑❑ Dropping Dependent(s)
❑❑ Decline GIC health insurance coverage
Annual Enrollment
❑ Address Change
❑❑ Name Change
Qualifying Status Change
�❑ Marriage
Birth/Adoption
❑ Divorce/Legal Separation
❑❑ Change in Dependent
Eligibility Status
❑❑ Gain of Other Coverage
Date of Event: / /
n Involuntary Loss of Other Coverage
❑ Return from FMLA or Military Leave
❑ Death of spouse/dependent
❑ Spouse's Annual Enrollment
❑ Moved out of health plan's service
area
HEALTH PLAN
Health
Plan
E Fallon Direct (HMO)
❑❑ Fallon Select (HMO)
❑❑ Harvard Pilgrim Independence (POS)
❑❑Harvard Pilgrim Primary Choice (HMO)
Effective Date:
g Health New England (HMO)
�❑ NHP Prime —Neighborhood Health Plan (HMO)
E Tufts Health Plan Navigator (POS)
❑❑ Tufts Health Plan Spirit (HMO -type)
Coverage Election: ❑ Individual ❑ Family
/ 01 /
g UniCare State Indemnity/Basic
CIC:❑❑YesONo
1 UniCare Community Choice (PPO-type)
n UniCare/PLUS (PPO-type)
Cancel Health Insurance Coverage: ❑❑Yes ❑❑ No
SPOUSE/DEPENDENT
INFORMATION
(See instructions an
back)
For Changes Only
LAST NAME
FIRST NAME
MI
SSN (REQUIRED)
DATE OF BIRTH
SEX
RELATIONSHIP
/ /
❑ Add ❑ Drop
❑ M ❑ F
/ /
❑ Add ❑ Drop
❑ M ❑ F
/ /
❑ Add ❑ Drop
❑ M ❑ F
❑AddnDrop
/ /
❑M ❑F
/ /
■❑Add ❑ Drop
❑ M ❑ F
FORMER SPOUSE INFORMATION — If Listed Above
Date of Divorce: / /
Are you remarried?
[Yes 7N
Date of your remarriage:
/ /
Has your former spouse remarried?
❑ Yes ❑ No
Date of former spouse's remarriage:
/ /
Address: Street
City
State
Zip
AUTHORIZATION — I have read the instructions on the reverse side of this form and authorize my employer, or direct my pension authority, to deduct from
my payroll or pension check the amount required for the coverage I have selected. I understand that due to IRS regulations, my health insurance coverage
elections are binding for the duration of the plan year and that I may only enroll in health insurance or change my coverage elections during the plan year
if I experience a qualifying status change (examples include marriage, adoption/birth of a child, death of a dependent, and involuntary loss of coverage).
I understand that the GIC must receive any required documentation for health insurance changes within 60 days of the event.
Signature of Applicant: Date:
Signature of Authorized Official: Date:
For GIC Use Only
Entered
Verified
Political Subdivision
(See over for Form-1MUN instructions)
1MUN - 3/18
MUNICIPAL ENROLLMENT/CHANGE FORM (FORM -1 MUN) INSTRUCTIONS
For an overview of your GIC benefit options, see your GIC Benefit Decision Guide mass.gov/service-details
benefit -decision -guides.
Deadlines and Required Documentation
• Required Documentation: To add a spouse or dependent to coverage, documentation is required. Refer to
dependent information section below for details.
• New Hire: Completed paperwork and required documentation must be received by your GIC Coordinator no
later than your 10th calendar day of regular, benefit eligible employment. If you miss the deadline, you must
wait until the next Annual Enrollment period to enroll in GIC health insurance benefits.
• Annual Enrollment: Completed paperwork and required documentation must be received by your GIC
Coordinator by the end of the Annual Enrollment period.
• Qualifying Status Change for Health Insurance: Municipal employees and retirees who have a qualified status
change during the year can enroll in GIC health insurance or change from individual to family or family to
individual coverage with proof of the family status change. Documentation of the event and the completed
form must be received at the GIC within 60 days of the qualifying event. Forms received after 60 days are
returned and you may re -apply during Annual Enrollment.
• Return from FMLA or Military Leave: If you voluntarily canceled GIC health insurance coverage at the
beginning of your FMLA or military leave of absence, you can re -enroll in GIC health insurance coverage
upon your return from leave. The enrollment form must be received at the GIC within 60 days of the return to
work. Forms received after 60 days are returned and you may re -apply during Annual Enrollment.
Work Hours and Eligibility
Active municipal employees must work at least 18.75 hours in a 37.5 -hour workweek or 20 hours in a 40 -hour
workweek and must contribute to your employer's public sector retirement system. For GIC purposes,
OBRA is not such a retirement system. For additional eligibility details, refer to the GIC's Regulations:
mass.gov/gic-regulations.
Dependent Information and Required Documentation
In order to enroll your eligible spouse, former spouse and/or dependents in GIC health insurance, you must
enter their information in the spouse/dependent box and provide a copy of a marriage certificate, birth
certificate or hospital announcement letter (newborns only), separation agreement, divorce decree, certificate
of appointment as legal guardian, etc., for each person you list as a dependent. If covering a former spouse,
also complete the former spouse information section. Failure to provide required documentation with this
enrollment/change form will result in your spouse/dependent not being covered. If you are deleting a spouse
or dependent under age 19, you must do so during Annual Enrollment or within 60 days of a qualifying event.
Under federal health care reform, Social Security Numbers must be provided for each spouse/dependent to be
covered under the health plan. For a newborn only, the Social Security Number can be provided at a later date.
Please indicate the exact date of birth for each dependent. To cover a dependent age 19 to 26, you must also
provide a completed Dependent Age 19 to 26 Enrollment and Change Form.
Form and Documentation Submission
Incomplete forms and insufficient required documentation may result in no coverage or a delayed effective date.
Active Employees: Return completed form and documentation to your GIC Coordinator.
(See over for Form-1MUN)
3/18