Transcription of GIC ENROLLMENT/CHANGE FORM (FORM-1) - …
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GIC ENROLLMENT/CHANGE FORM (FORM-1) - …
This document contains both information and form fields. To read information, use the Down Arrow from a form field. GIC ENROLLMENT/CHANGE form ( form -1). Health, Basic Life, Optional Life, and Long Term Disability Insurance INSURED INFORMATION. GIC-ID (usually Soc. Sec. #) Sex Date of Birth Dept. ID # or Agency/Division #. Insured M F / / /. Information Name Last First MI. REQUIRED. Street City State Zip Address Contact Home or Cell Phone Work Phone Email Country (if not USA). Information ( ) ( ). Employment Bargaining Unit/Union Name HR/CMS or UMASS Employee ID # Full-time Part-time Date of Hire Information Hours/week: / /. Select all that apply: Qualifying Status change Date of Event: ____ / ____ / _____.
(See over for Form-1) 3/17 ENROLLMENT/CHANGE FORM (FORM-1) INSTRUCTIONS For an overview of your GIC benefit options, see your GIC Benefit Decision Guide
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