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, 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.   

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

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

Documentation of the Qualifying Event 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.

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

When a marriage or state-registered domestic partnership is terminated, an ex-spouse or ex-domestic partner is no longer eligible for coverage as of the first month following the termination date. When an employee fails to submit the required forms and supporting court document within 31 days of the termination date, the employee is liable for claims paid beyond eligibility.  

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) Providence Medical Groups now available.
 - 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. Contact Personnel to also update the Designation of Beneficiary form for your last paycheck. 
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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: 

• Protected Health Info Release Form (optional)

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.