Forms

Forms (hard copy, original signature) must be completed and submitted (District Mail, US Mail, in-person; NO email or fax) to the GGUSD Insurance Department to process any change to your coverage for employees and/or dependents. Changes due to a qualifying event such as birth, adoption, marriage/domestic partnership, divorce or a change of eligibility status must be submitted within 31 days of the event or wait for the annual Open Enrollment period each October (effective January 1).  Effective date: first of month following qualifying event date. Plan changes only allowed at Open Enrollment.   

An additional 31 days from the effective date is afforded for you to provide copies of your recorded marriage certificate/California certificate of registered domestic partnership or birth certificates for your children and the SSN for a newborn.  Some documents available through Vital Statistics: http://www.cdc.gov/nchs/w2w.htm

Documentation of the Qualifying Event is required.  For loss of other coverage or newly acquired other coverage, a Letter of Creditable Coverage or HIPAA Certificate from the employer or prior carrier will suffice.

Important: Forms must be completed properly; please contact the Insurance Office for guidance. 

      ***PLEASE DO NOT SEND SENSITIVE INFORMATION (SSN, etc.) BY EMAIL***

HMO forms include a place for you to list a code for provider choice.  
 - Anthem Medical HMO Select Network Provider Finder Instructions (PCP ID: 3 or 6 digit alphanumeric)
 - Dental HMO Network Provider Info (United Concordia DHMO Concordia Plus) (Provider ID: 9 digit numeric)
If left blank, a provider close to your home is assigned. Provider changes may be requested at any time by calling the customer service number on the insurance card; allow up to 6 weeks processing time.

Update anytime: Life Insurance Beneficiary Designation Form Important: Update beneficiary contact information.  
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Initial Enrollment 
(Forms 1-3 mandatory; forms 4 or 5 only IF you choose either HMO plan) 

• 1-Health Benefits Enrollment & Change Form
• 2-Election and Authorization Form (For pre-tax contributions, sign both lines.) 
• 3-Life Insurance Beneficiary Designation Form
• 4-Anthem Blue Cross Medical HMO Enrollment Form (only if choosing this plan)
• 5-United Concordia Dental DHMO Enrollment Form (only if choosing this plan)
• Medicare Eligible Individuals: Important Medicare Part D Notice

Adding or Removing a Dependent:

• Health Benefits Enrollment & Change Form (mandatory form)
• Election and Authorization Form (only if change affects deduction amount - For pre-tax contributions, sign both lines.) 
• Life Insurance Beneficiary Designation Form (for new marriage/domestic partner or updating beneficiary information) 
• Anthem Blue Cross Medical HMO Form (only if enrolled in this plan)
  • HMO Medical Newborn Information
• United Concordia Dental DHMO Form (only if enrolled in this plan)
• Medicare Eligible Individuals: Important Medicare Part D Notice

Waiving Benefits

• Election and Authorization Form
• Life Insurance Beneficiary Designation Form
  

Miscellaneous Forms 

• Protected Health Info Release Form
• Health Insurance Marketplace Coverage

Contact the Insurance Office for the following forms: 

     - FSA Enrollment

     - Part-Time Life Insurance Beneficiary form: Employees eligible for CSEA, with a permanent assignment of at least 7.5 but less than 30 hours/week are provided a $20,000 life insurance benefit.