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MUNICIPAL ENROLLMENT/CHANGE (FORM1MUN) Health Insurance INSURED INFORMATIONREQUIREDGICID (usually Soc. Sec. #) Sex Insured Information Name LastAddressDate of Birth /Modest. ID # or Agency/Division

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How to fill out gic retireesurvivor enrollmentchange form

01

Obtain the GIC Retiree/Survivor Enrollment/Change Form from the GIC website or your employer.

02

Fill in your personal information, including your name, address, and social security number.

03

Indicate your healthcare coverage choices by checking the appropriate boxes for medical, dental, and vision coverage.

04

If you are making changes to your coverage, provide a reason for the change in the designated section.

05

Sign and date the form, and make a copy for your records before submitting it to the GIC or your employer.

Who needs gic retireesurvivor enrollmentchange form?

01

Retirees and survivors who are eligible for GIC healthcare coverage through their former employer.

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What is gic retireesurvivor enrollmentchange form?

The GIC Retiree/Survivor Enrollment Change Form is a document used by retirees or their survivors to make changes to their health insurance enrollment in the Group Insurance Commission (GIC) program.

Who is required to file gic retireesurvivor enrollmentchange form?

Retirees and their survivors who wish to change their health insurance plan or update their enrollment details are required to file the GIC Retiree/Survivor Enrollment Change Form.

How to fill out gic retireesurvivor enrollmentchange form?

To fill out the GIC Retiree/Survivor Enrollment Change Form, individuals need to provide their personal information, current enrollment details, any changes they wish to make, and sign the form before submitting it to the GIC.

What is the purpose of gic retireesurvivor enrollmentchange form?

The purpose of the form is to allow retirees or their survivors to officially notify the GIC of any changes in their health insurance enrollment, including switching plans or updating beneficiary information.

What information must be reported on gic retireesurvivor enrollmentchange form?

The form requires reporting personal identification information, current insurance plan details, requested changes to enrollment, and signatures of the retiree or survivor.

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