Signature of Applicant: ___________________________________________________________________________________ Date: _____________________________________
Signature of Authorized Official: __________________________________________________________________________ Date: _____________________________________
/ /
/ /
/ /
/ /
/ /
Date of Event: ____ / ____ / ________
Entered Verified Political Subdivision
–
Date of Divorce:
/ /
Date of your remarriage:
/ /
Date of former spouse’s remarriage:
/ /
Address: Street City State Zip
GIC-ID (usually Soc. Sec. #)
– –
Date of Birth
/ /
Dept. ID # or Agency/Division #
/
Name – Last First MI
Street City State Zip
Home or Cell Phone
( )
Work Phone
( )
Email Country (if not USA)
Date of Hire (must be completed):
/ /
Name of Municipality:
Number of work hours/week:
(See over for Form-1MUN instructions)
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
1MUN - 3/20
GIC MUNICIPAL ENROLLMENT/CHANGE FORM (FORM-1MUN)
Health Insurance
REQUIRED
INSURED INFORMATION
Insured
Information
Sex
M F
Address
Contact
Information
Employment
Information
REQUIRED FOR ALL NEW ENROLLMENTS
For Agency
Use Only
Does the employee participate in a public retirement system?
Yes No
Check one:
Full-time Part-time
REQUIRED
Select all that apply:
New Enrollment
Adding Dependent(s)
Dropping Dependent(s)
Decline GIC health insurance coverage
Annual Enrollment
Address Change
Name Change
Qualifying Status Change
Marriage
Birth/Adoption
Divorce/Legal Separation
Change in Dependent
Eligibility Status
Gain of Other Coverage
Involuntary Loss of Other Coverage
Return from FMLA or Military Leave
Death of spouse/dependent
Spouse’s Annual Enrollment
Moved out of health plan’s service
area
HEALTH PLAN
Effective Date:
/
01
/
Health
Plan
AllWays Health Partners Complete (HMO)
Fallon Direct (HMO)
Fallon Select (HMO)
Harvard Pilgrim Independence (POS)
Harvard Pilgrim Primary Choice (HMO)
Health New England (HMO)
Tufts Health Plan Navigator (POS)
Tufts Health Plan Spirit (HMO-type)
UniCare State Indemnity/Basic
UniCare Community Choice (PPO-type)
UniCare/PLUS (PPO-type)
CIC: Yes No
Coverage Election: Individual Family Cancel Health Insurance Coverage: Yes No
SPOUSE/DEPENDENT INFORMATION (See instructions on back)
For Changes Only
LAST NAME FIRST NAME MI SSN (REQUIRED)
DATE OF BIRTH
SEX
RELATIONSHIP
Add Drop M
F
Add Drop M
F
Add Drop M
F
Add Drop M
F
Add Drop M
F
FORMER SPOUSE INFORMATION If Listed Above
Are you remarried?
Yes No
Has your former spouse remarried?
Yes No
SIGNATURE REQUIRED
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 coverage). I understand that the GIC must receive any
required documentation for health insurance changes within 60 days of the event.
All divorces and remarriages must be reported to the Group Insurance Commission,
failure to notify the GIC of a legal separation, divorce, or remarriage can result in financial liability to you.
For GIC Use Only
City of Framingham - Framingham Public Schools
666
0100
