How to Fill Out and Submit GIC Form 1A: Deadline and Coverage

Massachusetts GIC Form 1A is the Group Insurance Commission’s paper form for reporting an employment status change — a leave of absence, a transfer between participating agencies, a termination, or a retirement. Despite the name, it is not an initial enrollment form. Most GIC members handle new enrollments and annual changes through the MyGICLink online portal, and Form 1A exists as the paper alternative for members who cannot use the portal.¹ You can download it from the GIC Print Forms page on Mass.gov or ask your agency’s GIC Coordinator for a copy.²

When to Use Form 1A

The form has three main sections, and you fill out only the one that fits your situation.

Leave of absence. Personal illness, military service, FMLA, maternity, sabbatical, suspension, paid family and medical leave, and other leave types. You indicate whether the leave is with or without pay and choose which benefits to maintain while out.
Transfer or termination. Moving between GIC-participating agencies or ending state employment. This section also covers 39-week layoff status, deferred retiree elections, COBRA continuation, and conversion to an individual policy.
Retirement. Moving from active employee benefits to retiree coverage, with health plan elections, Medicare coordination, optional life insurance decisions, and retiree dental enrollment.

If you are a new hire enrolling for the first time, or a current employee changing plans during annual enrollment, use MyGICLink rather than Form 1A. The portal also handles qualifying-event changes within 60 days of the event.³

Documents to Gather Before You Start

The GIC requires proof of eligibility for any dependents on your coverage. An incomplete package can delay your effective date or leave you with no coverage, so pull these together first.¹

For a dependent child: a certified birth certificate showing the parent-child relationship.
For a spouse: a certified government-issued marriage certificate. Civil union partners are not eligible for GIC health insurance; only legal spouses qualify.⁴
For a divorce: specific pages of the divorce decree, including the divorce absolute date, the signature page, the health insurance provisions, and your former spouse’s last known address.⁵

Any supporting document in a language other than English must be submitted with a certified translation and a copy of the original. The translation must come from an independent person or company who certifies it is true and accurate, and you pay for it.⁵

Employees opting out of GIC health coverage must show proof of other employer-sponsored insurance that meets IRS minimum value criteria.

Filling Out the Form

Form 1A is a single page with instructions on the back. Work from the top down, and complete only the section that matches your status change.

Insured Information

Enter your GIC-ID, which is usually your Social Security number. The form also asks for your sex, date of birth, full name, residential address, preferred phone number, and preferred email. Then fill in your employment details: bargaining unit or union name, HR/CMS or UMass employee ID, hours worked per week, salary effective date, annual salary, and department ID or agency/division number.¹

Leave of Absence

Mark whether the leave is with or without pay and check the leave type (FMLA, military, personal illness, maternity, PFML, and so on). Then choose which benefits to keep while out: basic life, health, long-term disability, optional life, or GIC dental and vision. You can also cancel all coverage. Enter your leave start date, expected end date, and last day on payroll.

Watch this section carefully. If you cancel health insurance during FMLA or military leave and want it back when you return, the GIC must receive your completed Form 1A within 60 days of your return-to-work date. Miss that window and you wait until the next annual enrollment to reinstate coverage. Members returning from military leave who cancelled all GIC benefits have the right to reinstate everything upon return.¹

Transfer or Termination

For a transfer, list the agency you are leaving with your last day of work, and the agency you are joining with your hire date. For a termination, write in the reason and your last day of work. Additional checkboxes cover 39-week layoff, deferred retiree status (life only or life and health), COBRA continuation, and conversion to an individual policy.

Retirement

This is the most detailed section. Enter your retirement date and select your health insurance plan. If you or your spouse are Medicare-eligible, indicate that so the GIC can coordinate your plan with Medicare. Choose what to do with optional life insurance: cancel it, reduce it to a fixed amount, keep your current coverage, or reduce it to a multiple of salary. A separate checkbox lets you enroll in GIC retiree dental.

Signatures

Sign and date the form at the bottom. Your signature authorizes your employer or pension authority to deduct the required amounts from your payroll or pension check for the coverage you selected. An authorized official from your agency also signs before the form goes to the GIC.¹

How to Submit It

You have two options. Email the completed form and all supporting documents to gic.forms@mass.gov, or mail the paper package to:

Group Insurance Commission
PO Box 556
Randolph, MA 02368¹

In most agencies, your GIC Coordinator reviews the form for completeness before it goes out. Coordinators are the point people within each agency who help employees with GIC paperwork and benefit questions.⁶ If you mail it yourself, use a method with tracking. An incomplete form or missing documentation can result in no coverage or a delayed effective date.

The 60-Day Deadline

Outside of annual enrollment, you can only change your GIC benefits within 60 days of a qualifying life event. The GIC recognizes these events:

Marriage
Birth or adoption
Divorce or legal separation
Death of a spouse or dependent
A spouse’s or dependent’s employer open enrollment period
Change in a dependent’s eligibility status
A spouse or dependent moving to the United States
Loss of Medicaid or CHIP coverage
Court order or judgment
Moving out of your health plan’s service area
Change in employment status

Any request received after the 60-day window is denied, and you wait until the next annual enrollment period.⁴ One common trap: open enrollment through the Massachusetts Health Connector or another state’s insurance exchange is not a qualifying event for the GIC. Failure to notify the GIC of a divorce, legal separation, or remarriage can leave you financially liable for any claims paid on behalf of an ineligible dependent.¹

When Coverage Takes Effect

The effective date depends on your situation.

New hires who start on the first of the month have benefits effective that day. If your start date falls on any other day, coverage begins the first of the following month. The old 60-day waiting period for new employees was eliminated by a law that took effect July 1, 2024.⁷⁸
Annual enrollment runs April 1 through May 1, with all changes effective July 1.⁹
For qualifying-event changes, the effective date depends on when the GIC receives your completed form and documentation within the 60-day window.

Insurance cards are mailed to your home address within several weeks of your coverage effective date. Check your pay stubs to confirm that premium deductions match the plan you selected; the GIC Benefit Guides published each spring list the exact premium amounts for every plan.¹⁰ If something looks off, contact your GIC Coordinator to correct it before the next pay cycle.

1
Mass.gov. Employment Status Change Form 1A
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Group Insurance Commission. GIC Print Forms
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Mass.gov. MyGICLink Member Benefits Portal
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Mass.gov. GIC Qualifying Events
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Group Insurance Commission. Required Documents for GIC Coverage
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Mass.gov. GIC Coordinator Resources
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Mass.gov. Employment, Eligibility, and GIC Benefits
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Mass.gov. New Hire Benefits Law Effective July 1, 2024
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Mass.gov. Group Insurance Commission Annual Enrollment
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Group Insurance Commission. Benefit Guides