Forms

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 Oct., effective Jan. 1). See forms below to be completed for enrollment or common changes; original signature required; must be received within 31 days of the qualifying event.

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.

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

Please contact the Insurance Department with any questions.

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

• Flexible Spending Account Enrollment Form 2021 (Allowed at Open Enrollment or Qualifying Event)
• Protected Health Info Release Form
• New Health Insurance Marketplace Coverage