Benefits Forms

GIC Health Insurance

It is now possible to complete and sign ALL GIC enrollment forms electronically through a secure email link. This new electronic capability, myGIC Link, streamlines the benefit enrollment and change process. Simply call the Employee Benefits Dept. at (413) 787-6055 or email:, provide us with an email address, and the link will be forwarded to you immediately.

Please review the list of additional required documents if you have dependents or are turning 65!

Are you a new hire or did you have a change in status? Are you changing your plan during Open Enrollment? 

GIC Municipal Insurance Enrollment/Change Form - This form (Form-1MUN 1/21) is for enrolling in or changing your election of health insurance. Use this form as a new hire, at Annual Enrollment, within 50 days of a documented qualifying status change, name and address changes, and for divorce and remarriage notifications. Use this form to add or drop your spouse and dependent(s) from coverage during Annual Enrollment and within 50 days of a documented qualifying status change.

*If you are enrolling for the First Time please also fill out the Benefits Acknowledgement Form along with the Form-1MUN.

*If you are Opting-Out of an insurance plan this fiscal year, please fill out the Health Insurance Refusal Form.

Are you transferring to the CIty from another GIC entity? Are you retiring or a retiree that needs to make changes to your health insurance? 

GIC Municipal Status Change Form - This form (Form-1AMUN 1/21) is for when you have an employment status change including transferring to or from your municipality, terminating municipal employment, and at retirement.

Retiree/Survivor Enrollment/Change Form - This form (Form- RS 1/21) is for state and municipal retirees and survivors.  Use this form to enroll in GIC health insurance coverage for the first time at retirement, during Annual Enrollment, for an address or name change, within 60 days of a documented qualifying status change, and if you are a new municipal survivor applying for coverage for the first time. During Annual Enrollment and within 60 days of a qualifying status change, you can also use this form to cancel coverage, and add or drop your spouse or dependent(s).

Do you have a dependent between the ages of 19 and 26 and need to add or update information?  Please use this form.

Dependent Aged 19 to 26 Form - Use this form to add your dependent age 19 to 26 to your coverage as a new employee, during Annual Enrollment, or to change your covered dependent’s status when he/she becomes a full-time student outside of the health plan’s service area or when he/she no longer is a full-time student.

Flex Spending Accounts (FSA) & Voluntary Benefits

**For Active Eligible Employees Only**

Introducing the City’s New FSA & Voluntary Benefits Provider

Enroll April 7, 2021 – May 14, 2021

The City has partnered with American Fidelity (AFA) as our New Supplemental Benefits and Section 125 Plan provider. American Fidelity specializes in servicing public sector employees and currently serves government employees across the country. Along with enrollment, AFA prioritizes benefits education to help you make the best choices for you and your family.

Employees may continue their existing Voluntary Benefit policies with AFLAC and Trustmark through a post-tax payroll deduction; that will continue to be paid on their behalf directly to these vendors by the City. New enrollments with AFLAC will no longer be an option for employees effective June 30, 2021. Trustmark will continue to be an enrollment option for employees beyond June 30, 2021 and more details will be provided in the near future regarding the time period to enroll in Trustmark or make changes to your existing policy outside of open enrollment.

Schedule your AFA appointment today for a personalized meeting with an account manager by using the following web link or call 1-888-279-0067:

  • What will be covered during the meeting?
    • American Fidelity will confirm your benefits for the upcoming plan year. They will also review pre-tax options, including Flexible Spending Accounts. If you are currently participating in the FSA benefit, you are required to RE-ENROLL for the new plan year July 1, 2021 through June 30, 2022.
  • What do I need to bring to my appointment?
    • You’ll need dates of birth and social security numbers for dependents who are being covered on your benefits. If you're adding a spouse or dependent child, additional documents may be required.
  • Will I have the option to find out more about additional supplemental benefits?
    • Yes, you’ll be able to learn more about benefit options that could be important to you and your family such as disability insurance, life insurance, and accident insurance protection.

Connecting to your AFA meeting on the date of your appointment:

  • Step     1          Your account manager will contact you by phone.
  • Step     2          Visit through your preferred web browser.
  • Step     3          Provide your account manager with your unique PIN to begin screen sharing.
  • Step     4          The account manager will walk you through enrollment and educate you on

Flexible Spending Accounts   

                                                       Annual Minimum               Annual Maximum

Health Care Accounts                             $250                                    $2,750

Dependent Care Accounts                      $500                                    $5,000

Please be advised that you must be Eligible for health insurance to enroll in FSA, but you do not need to enroll in health insurance to sign up for FSA/DCFSA. The waiting period for FSA is the same as GIC Health Insurance. 

Deferred Compensation Program

If you wish to join the SMART Plan and begin your contributions, you must complete a new enrollment form.  Completed forms can be mailed or delivered to the City of Springfield, Attention: Benefits Department, 36 Court Street, Room 18, Springfield, MA 01103.  Please ensure that all information requested on the form is complete. We will not be able to process forms until all of the information is correct. Please note that SMART Plan enrollment can be completed at any time during the year.

If you would like to obtain more detailed information regarding the SMART Plan, please visit their website at or call 877.457.1900

For quick and convenient service, contact your local representative:

Dan Moroney, CFP at 413-335-0542 or (Police & Fire)

Life Insurance Plans

The City currently offers Basic and Supplemental Life insurance through Guardian Life Insurance! 

Do you want to enroll in life insurance or make changes to your existing life insurance?  Please use this form.

Guardian Life Insurance Enrollment/Change Form

Do you want to convert your City's life insurance policy to an individual policy upon ending employment? Please use this application and submit it directly to the Guardian Life Insurance Company.

Guardian Life Insurance Conversion Application

Downtown Parking for Employees

Please fill out the forms below to set up your parking deduction

SPA Monthly Parking Agreement

Monthly Parking Deduction Form - This form authorizes the City to deduct payment for your parking from your paycheck*

Forms may be emailed to or sent to Benefits Room 018

*Please Note: Authorization for payroll deduction must be given prior to the first day of the month that parking will begin in order for the City to begin payment.

Page last updated:  Saturday, April 3, 2021 12:10 pm