Form-1a - Gic Employment Status Change Form

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GIC EMPLOYMENT STATUS CHANGE FORM

(FORM-1A)

INSURED INFORMATION

GIC-ID (usually Soc. Sec. #)

Sex

Dept. ID # or Agency/Division #

Date of Birth

–

Insured

Information

Name – Last

First

Street

City

State

Zip

Address

Home or Cell Phone

Work Phone

Country (if not USA)

Contact

(

)

(

)

Information

Bargaining Unit/Union Name

HR/CMS or UMASS Employee ID #

Number of work

Date of Hire

Employment

hours/week:

Information

LEAVE OF ABSENCE

Effective Date

(for GIC use only)

Select One:

Leave with pay

Cancel Coverage:

Long Term Disability (LTD)

Health Insurance

Optional Life Insurance

Leave without pay

GIC Dental/Vision

Leave Start Date:

Select Type of Leave (Form-11) required for Individual Accident, Maternity and Personal Illness

______ / ______ / __________

Personal Illness

Personal Reason

Military

Leave End Date:

______ / ______ / __________

Individual Accident

Educational

Military Caregiver (26 weeks)

Last Day on Payroll:

______ / ______ / __________

FMLA (12 weeks)

Sabbatical

FMLA Military Exigency (12 weeks)

Return from Leave Date:

______ / ______ / __________

Maternity

Suspension

Other

TRANSFERS AND TERMINATION

Effective Date

(for GIC use only)

Transfer to

Name of Agency/GIC Municipality

Last Day of Work:

Transfer from

Name of Previous Agency/GIC Municipality

Hire Date:

Termination of Service

Termination reason

Last Day of Work:

Coverage (if elected)

39-week Layoff Coverage

Deferred Retiree

COBRA (must complete COBRA application)

Conversion (contact carrier for application)

RETIREMENT

Date Retired:

Effective Date

(for GIC use only)

Health Insurance Election (If enrolling for first time, also complete Form-RS)

Cancel Health Insurance

Medicare Eligibility – check if applicable and attach copy of Medicare Claim Card(s):

Insured

Spouse

Medicare Plan name:________________________________________________________

Non-Medicare Plan Election for insured or spouse not eligible for Medicare:

Keep current health plan

Change Non-Medicare Plan election to Plan name:___________________________________________________

Optional Life Insurance Election

Cancel Optional Life

Reduce Optional Life to Fixed Amount: $__________

Keep current Optional Life coverage

Reduce Optional Life multiple of salary to:

GIC Retiree Dental

I wish to enroll in GIC Retiree Dental and have attached the completed GIC Retiree Dental Enrollment and Change Form

I do not wish to enroll in the GIC Retiree Dental at this time

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 other coverage). I understand that the GIC must receive any

required documentation within 60 days of the event.

Signature of Applicant: __________________________________________________________________________________

Date: ___________________________________

Signature of Authorized Official: _________________________________________________________________________

Date: ___________________________________

Entered

Verified

Political Subdivision

For GIC Use Only

(See over for Form-1A instructions)

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