MA Form-RS 2017 free printable template

This document contains both information and form fields. To read information, use the Down Arrow from a form field. GIG RETIREE/SURVIVOR ENROLLMENT/CHANGE FORM (FORMS) INSURED INFORMATIONREQUIREDGICID

How to fill out gic retireesurvivor enrollmentchange form

How to fill out gic retireesurvivor enrollmentchange form

1. To fill out the GIC Retiree/Survivor Enrollment/Change Form, follow these steps:
2. Print the form from the GIC website or obtain a copy from your employer or HR department.
3. Fill in your personal information, such as your full name, Social Security number, address, and contact details.
4. Provide information about your current health insurance plan and coverage, including the plan name and policy number.
5. Indicate whether you are enrolling for the first time, making a change to your existing coverage, or canceling your coverage.
6. If making a change, specify the effective date of the change and provide details about the new plan or coverage.
7. Review the form for accuracy and completeness.
8. Sign and date the form.
9. Submit the completed form to the appropriate party, such as your employer or HR department, as instructed.

Who needs gic retireesurvivor enrollmentchange form?

1. The GIC Retiree/Survivor Enrollment/Change Form is needed by retired individuals or survivors who wish to enroll or make changes to their health insurance coverage provided by the Group Insurance Commission (GIC). This form is typically required for retirees and survivors who are eligible for GIC health insurance benefits through their former employer or deceased family member's employment.

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