Benefit Forms
Below is a listing of benefit forms for the various benefit options available to you.
Benefit Form Submission ProcessBenefit Form Instructions*Benefits Form Submission (Non-GIC Benefits)
*The UMass Chan benefits (non-GIC benefits) for Open Enrollment are Dental Insurance, Vision Insurance, Child Care Assistance Program, and Short Term Disability. |
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GIC Form Submission Process |
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**GIC Form Submission Online: Go to the MyGICLink member benefits portal to make benefit changes and submit form documentation.
Or, go to bit.ly/mygiclink to request electronic GIC forms be emailed to you and complete online to submit. Follow instructions on mygiclink web site. **UMass Chan GIC Open Enrollment benefits are Health Insurance, Health Insurance Buy-Out Option, Health Care Spending Account, and Dependent Care Assistance Program. |
**GIC Form SubmissionMail:
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Health Insurance Forms
GIC Enrollment/Change Form (Form 1) Use this form to enroll, change or cancel your health insurance coverage.
GIC Dependent Age 19 to 26 Enrollment/Change Form Use this form to enroll or change status for a dependent age 19 to 26.
GIC Health Insurance Buy-Out Form Use this form to participate in the Health Insurance Buy-Out program.
GIC Application to Continue Part Cost Premiums (Form 11) Use this form to apply for a reduction of monthly premium if out on an approved leave of absence.
GIC Employment Status Change Form (Form 1A) Use this form for an employment status change (including retirement).
State Employee Acknowledgement and Waivers Form Use this form to acknowledge that you've reviewed the most recent GIC Benefits Decision Guide and understand your benefit options and to waive Basic Life and/or Long-Term Disability Insurance.
Dental Insurance Forms
Cigna Dental Enrollment/Change Form Use this form to enroll, make changes, cancel coverage or add dependents to your dental plan.
Cigna Dental PPO (DPPO) Dentist Nomination Form Use this form to nominate your dentist to be added to the CIGNA Dental PPO network.
Vision Insurance Form
Guardian Vision Enrollment Form Use this form to enroll, make changes or cancel your vision coverage.
Optional Life Insurance Forms
GIC Enrollment/Change Form (Form 1) Use this form to enroll, change or cancel your Optional Life Insurance coverage.
GIC Life Insurance Beneficiary Form - 319 Use this form to change your beneficiaries for the GIC Life Insurance plan (up to 3 beneficiaries). It can only be submitted via GIC Online Forms.
GIC Life Insurance Beneficiary Form G-500 Use this form to change your beneficiaries for the GIC Life Insurance plan (for 4 or more beneficiaries, Estates and Trust Designations). It can only be submitted via GIC Online Forms.
Short-Term Disability Forms
Short-term Disability Enrollment Form Use this form to enroll in the Short-Term Disability Plan. (Use Internet Explorer Only to Open and Submit this Form)
Request for Leave of Absence Form Use this form to request a leave of absence.
Long-Term Disability Form
GIC Enrollment/Change Form (Form 1) Use this form to enroll, change or cancel your Long-Term Disability (LTD) coverage.
Sick Leave Bank Forms
Sick Leave Bank Enrollment Form Use this form to enroll in the Sick Leave Bank program.
Sick Leave Bank Request Form Use this form to request Sick Leave Bank time.
Health Care Spending Account & Dependent Care Assistance Programs
To enroll in the Health Care Spending Account (HCSA) or the Dependent Care Assistance Program (DCAP), go to benstrat.com/gic-fsa.
Child Care Assistance Handbook/Forms
Child Care Assistance Handbook
For questions on the Child Care Assistance program, contact the Benefits Department at benefits.umms@umassmed.edu or (508) 856-5260, Option 1.
Massachusetts State Employee Retirement System (MSERS) Forms
State Retirement Enrollment Form Use this form to enroll in the MSERS.
State Retirement Beneficiary Selection/Change Form Use this form to add or change beneficiaries on your MSERS account.
State Retirement BuyBack Request Form Use this form to purchase service for your MSERS account.
State Retirement Contract Service BuyBack Form Use this form to purchase contract service for your MSERS account.
State Retirement Refund/Rollover Request Form Use this form to apply to withdraw accumulated pension deductions from the MSERS.
State Retirement Option D Form Use this form to nominate an eligible beneficiary to receive Option C retirement allowance.
Social Security Form (SSA-1945) Acknowledgement form on the possible effects of the Windfall Elimination Provision on future Social Security Benefits.
State Retirement Application Use this form to file for retirement.
Prior Service Form Use this form to verify prior public service.
Optional Retirement Program (ORP) Forms
Note: You must be eligible to enroll in the Optional Retirement Program (ORP). You will be notified by the Benefits Department in the HR Service Center within your first 2 weeks of hire if eligible. Please note: Do not complete enrollment forms or open a vendor account until you are notified of your ORP eligibility by the Benefits Department.
Notice of ORP Eligibility Use this form to confirm receipt of eligibility in the ORP.
ORP Enrollment-Change Form Use this form to enroll in the ORP.
MSERS Refund/Rollover Request Form Use this form to request a refund or rollover from the MSERS.
SSA-1945 Form Use this form to acknowledge receipt of possible effects of the ORP on any potential future Social Security benefits.
Standard Insurance Enrollment and Change Form Use this form to enroll and designate beneficiaries for the ORP Life and ORP LTD Insurance.
403(b) Plan Forms
403(b) One-Time Payout Deferral Form Use this form for a one-time 403(b) deferral for sick and/or vacation payout upon separation or retirement.
457(b) Plan Forms
457(b) Sick & Vacation Pay Deferral Form Use this form for a one-time 457(b) deferral for sick and/or vacation payout upon separation or retirement.
Tuition Forms
Tuition Credit & Remission Form Use this form to apply for tuition credit or remission.
Tuition Assistance Form Use this form to apply for tuition assistance.
Educational Partnership Authorization Forms
Assumption University Authorization Form - Graduate Program This form attests that you are a UMass Chan employee eligible for the Assumption University Graduate program.
Clark University Partnership Program (CUEP) Authorization Form This form attests that you are a UMass Chan employee eligible for the Clark University Partnership program.
Other Forms
Adoption Assistance Reimbursement Request Form Use this form to apply for reimbursement of eligible adoption expenses (up to a maximum of $1,000 per child).
Employee Record Change Form Use this form for a legal name change.
Frequently Asked Questions (FAQ's)
ACA (Affordable Care Act) Glossary A glossary of Affordable Care Act (ACA) terms.
ACA (Affordable Care Act) FAQ's A listing of frequently asked Affordable Care Act (ACA) questions.
Form 1095-B FAQ's A listing of frequently asked questions on Form 1095-B.
Form 1095-C FAQ's A listing of frequently asked questions on Form 1095-C.
MA Sick Time FAQ's A listing of frequently asked questions on earned paid sick leave.