Revised 2/20
DEPENDENT AGE 19 TO 26 ENROLLMENT/CHANGE FORM FEDERAL HEALTH CARE REFORM (ACA)
Use this form to enroll your dependent age 19 to 26 for the first time or to report your dependent’s age 19 to 26 status change. Upon receipt of a complete
application, the GIC will determine coverage eligibility and effective date. For new insureds, coverage for the dependent age 19 to 26 will begin on the new
insured’s effective date. Dependents of existing GIC enrollees who are already over age 19 must have a qualifying event to enroll during the year or may apply
during the GIC’s Annual Enrollment. Incomplete applications will be returned. PLEASE USE ONE FORM FOR EACH DEPENDENT AGE 19 TO 26.
I am applying for coverage or reporting a status change for my dependent age 19 to 26. The GIC may require proof of relationship
for the dependent you plan to cover and will contact you for any documents, if necessary.
Name of Insured________________________________________ Social Security # _________________
________________________________________________ Telephone #____________________
Address
________________________________________________ PLEASE COMPLETE ONLY ONE SECTION BELOW
City State Zip SECTION A ENROLL YOUR DEPENDENT
SECTION B CHANGE DEPENDENT STATUS
A) ENROLLMENT DEPENDENT AGE 19 TO 26 Use this section to enroll your dependent
Name of Dependent Age 19 - 26_______________________ Social Security #___________________
_____________________________________________ Dependent’s Date of Birth ___________
Address
______________________________________________________ Relationship to Insured ______________
City State Zip
______Check here if your dependent is a full-time student attending an accredited institution outside your health plan’s
service area and provide school name and address below: (Check with your health plan for benefits available to full-time students
that are attending school outside the service area.)
Name of School ________________________________ School Address ________________________________
(That is outside health plan’s service area) ________________________________
You must contact the GIC when your dependent is no longer a full-time student to continue coverage to age 26.
B) CHANGE OF DEPENDENT’S AGE 19 TO 26 STATUS Use this section to report dependent address and full-time student status changes
Name of Dependent Age 19 - 26_______________________ Social Security #___________________
_______________________________________________________ Dependent’s Date of Birth ___________
Address
______________________________________________________ Relationship to Insured ______________
City State Zip
______Dependent Address Change New Address: _______________________________________
_______________________________________
______Dependent is no longer a full-time student as of ________________________.
(Date)
SIGNATURE REQUIRED Please sign and date below
Full-time student and non-student adult children age 19-26 may reside outside of your health plan’s service area but will be subject to the plan’s
coverage rules. Be sure to review your plan’s out of service area coverage and consider whether you should change to a plan providing greater
geographical coverage for your dependent. Under the pains and penalties of perjury, I attest that all statements I have made on this form are
true. I understand that if I misrepresent or provide false or incomplete information on this form my GIC coverage may be terminated (possibly
retroactively), in addition to other legal remedies and financial consequences, at the GIC’s discretion.
Signature of Insured ______________________________________ Date ___________________
Form and Document Submission: Incomplete forms and insufficient required documentation may result in no
coverage or a delayed effective date. ONLINE: Visit bit.ly/myGICLink to request and submit your enrollment
form(s). MAIL: Return completed form and documentation to Commonwealth of Massachusetts-Group Insurance
Commission, PO Box 556, Randolph, MA 02368
GIC USE ONLY APPROVED _________Effective Date __________ Expiration Date ________
DENIED ________
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