Forms

See forms below to be completed for enrollment or common changes. 

Forms must be completed and submitted to the GGUSD Insurance Dept. to process any change to your coverage for yourself and/or your dependents. You must have a qualifying event to add/remove yourself and/or your dependents outside of Open Enrollment (mo. of Nov., effective Jan. 1). Forms must be received within 31 days of the qualifying event. Originals with wet signature required. 

An additional 31 days from the effective date is afforded for you to provide a copy of your recorded marriage certificate or registration of domestic partnership and birth certificates for your children and the SSN for a newborn.

When newly married, an updated Life Insurance Beneficiary Designation form must be submitted.

Please contact the Insurance Department with any questions.

Our next Open Enrollment period is October 24 - November 30; plan changes are submitted for a January 1, 2023 effective date.   

Our PPO and EPO Medical plans have a new Third Party Administrator effective 1/1/22: HealthNow (HNAS) www.myhnas.com / 855-539-0020. New cards were mailed in December for use after 12/31/21. 

***PLEASE DO NOT SEND SENSITIVE INFORMATION BY EMAIL.***

Initial Enrollment 
(Forms 1-3 are mandatory; also include forms 4 or 5 IF you choose either HMO plan)

• Health Benefits Enrollment & Change Form
• Election and Authorization Form (for pre-tax contributions, sign both lines)
• Life Insurance Beneficiary Designation Form
• Anthem Blue Cross HMO Enrollment Form (only if you choose this plan)
• United Concordia DHMO Enrollment Form (only if you choose this plan)

Adding or Removing a Dependent:

• Health Benefits Enrollment & Change Form (mandatory form)
• Election and Authorization Form (only if your deduction is changing - for pre-tax deductions, sign both lines)
• Life Insurance Beneficiary Designation Form (only if newly married or changing beneficiary) 
• Anthem Blue Cross HMO Enrollment Form (only if enrolled in this plan)
• United Concordia DHMO Enrollment Form (only if enrolled in this plan)

Waiving Benefits

• Election and Authorization Form
• Life Insurance Beneficiary Designation Form

Miscellaneous Forms

• HMO Member Claim Form
• HNAS COVID At Home Test Kit Reimbursement Claim Form
• CVS CAREMARK COVID-19 OTC AT HOME TEST REIMBURSEMENT INSTRUCTIONS
• CVS Caremark Prescription Reimbursement Form
• Protected Health Info Release Form
• New Health Insurance Marketplace Coverage