Are you a new hire or did you have a change in status? Are you changing your plan during Open Enrollment? Please use this form to enroll in a health insurance plan or to make changes to your existing plan!
GIC Municipal Insurance Enrollment/Change Form - This form (Form-1MUN 3/19) is for enrolling in or changing your election of health insurance. Use this form as a new hire, at Annual Enrollment, within 50 days of a documented qualifying status change, name and address changes, and for divorce and remarriage notifications. Use this form to add or drop your spouse and dependent(s) from coverage during Annual Enrollment and within 50 days of a documented qualifying status change.
*If you are enrolling for the First Time please also fill out the GIC Acknowledgement of Coverage Form along with the Form-1MUN.
Are you transferring to the CIty from another GIC entity? Are you retiring or a retiree that needs to make changes to your health insurance?
GIC Municipal Status Change Form - This form (Form-1AMUN 3/19) is for when you have an employment status change including transferring to or from your municipality, terminating municipal employment, and at retirement.
Retiree/Survivor Enrollment/Change Form - This form (Form- RS 3/19) is for state and municipal retirees and survivors. Use this form to enroll in GIC health insurance coverage for the first time at retirement, during Annual Enrollment, for an address or name change, within 60 days of a documented qualifying status change, and if you are a new municipal survivor applying for coverage for the first time. During Annual Enrollment and within 60 days of a qualifying status change, you can also use this form to cancel coverage, and add or drop your spouse or dependent(s).
Do you have a dependent between the ages of 19 and 26 and need to add or update information? Please use this form.
Dependent Aged 19 to 26 Form - Use this form to add your dependent age 19 to 26 to your coverage as a new employee, during Annual Enrollment, or to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area or when he/she no longer is a full-time student.
**For Active Eligible Employees Only**
FSA/Dependent Care Account Reimbursement Form (TakeCare by Wageworks)
Please be advised that you must be Eligible for health insurance to enroll in FSA, but you do not need to enroll in health insurance to sign up for FSA/DCFSA. The waiting period for FSA is the same as GIC Health Insurance.
If you wish to join the SMART Plan and begin your contributions, you must complete a new enrollment form. Completed forms can be mailed or delivered to the City of Springfield, Attention: Benefits Department, 36 Court Street, Room 18, Springfield, MA 01103. Please ensure that all information requested on the form is complete. We will not be able to process forms until all of the information is correct. Please note that SMART Plan enrollment can be completed at any time during the year.
If you would like to obtain more detailed information regarding the SMART Plan, please visit their website at www.mass-smart.com or call 877.457.1900
For quick and convenient service, contact your local representative:
Heather Kane, CRC at 781-296-9948 or Heather.Kane@Empower-Retirement.com
Dan Moroney, CFP at 413-335-0542 or Dan.Moroney@Empower-Retirement.com (Police & Fire)
The City currently offers Basic and Supplemental Life insurance through Guardian Life Insurance!
Do you want to enroll in life insurance or make changes to your existing life insurance? Please use this form.
Please fill out the forms below to set up your parking deduction
Monthly Parking Deduction Form - This form authorizes the City to deduct payment for your parking from your paycheck*
Forms may be emailed to firstname.lastname@example.org or sent to Benefits Room 018
*Please Note: Authorization for payroll deduction must be given prior to the first day of the month that parking will begin in order for the City to begin payment.