Benefit Forms

Below is a listing of benefit forms for the various benefit options available to you.

Benefit Form Submission Process Benefit Form Instructions ​​​​​​​*Benefits Form Submission (Non-GIC Benefits) For non-GIC forms, you may choose and access the applicable form(s) on this webpage and submit online via the instructions in the form.   All New Hires, please fill out Benefits Forms as instructed for New Hires. *The UMass Chan benefits (non-GIC benefits) for Open Enrollment are Dental Insurance, Vision Insurance, Child Care Assistance Program, and Short Term Disability.
GIC Form Submission Process
**GIC Form Submission ​​​​​​​ Online: Go to the MyGICLink member benefits portal to make benefit changes and submit form documentation. If you are already registered, login at bit.ly/MyGICLinkLogin. (URL is case sensitive) If you are not registered, login at bit.ly/MyGICLinkRegistration. (URL is case sensitive) 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 Submission  Mail:  Choose and access your GIC form(s) by clicking the applicable GIC form(s) links on this site Follow instructions for completion of the form(s) Save a completed copy on your computer Print out a completed copy of the form(s) and sign the hard copy(s) (requires an ink signature) Mail and return completed form(s) and documentation to Commonwealth of Massachusetts-Group Insurance Commission, PO Box 556, Randolph, MA 02368

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

Child Care Assistance Form

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.