GIC Forms and Rates
- FY19 Rates
- GIC MUNICIPAL ENROLLMENT/CHANGE FORM (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.
- GIC MUNICIPAL EMPLOYMENT STATUS CHANGE FORM (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.
- GIC 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).
- $53.86/month for Individual Coverage
- $130.17/month for Family Coverage
- DELTA Dental Benefits Summary
- DELTA Dental Enrollment Form
FLEX SPENDING CPA
- Winthrop Notice
- Eligible Expenses
- Important Information about your PREPAID Benefits Card
- FSA Store
- Enrollment Form
- Dependent Care Claim