Required Documents for GIC Coverage

Required documentation needed when submitting an application for GIC coverage: e.g. birth, adoption, and marriage certificates, divorce decrees, or guardianship and court documents.

Documents such as marriage certificates and birth certificates can be obtained by contacting the Clerk’s Office of the town in which the event occurred. We encourage you to contact the appropriate offices as soon as possible. There may be a waiting period to obtain information.

If mailing required documents, do not send original documents because they will not be returned.

To Cover Yourself Only

Non-Medicare: There is no documentation needed.

Medicare: If you and/or your spouse are on Medicare, see the Additional Documents for Retirees and Survivors section below.

To Cover a Current or Former Spouse

• If you are married: Copy of Certified Marriage Certificate
• If you are divorced: the following sections of the divorce decree are required.
  • Divorce Absolute Date
  • Signature Page
  • Health Insurance Provisions
  • Your Former Spouse’s Last Known Address
• Note: If you were divorced prior to March 27, 1985, or either you or your former spouse has remarried, your former spouse is not eligible for GIC coverage.

To Cover Dependent Children

• Dependent child coverage: Copy of certified birth certificate with parent/child relationship listed
  • If the dependent is disabled and over age 19, you may also complete the Disabled Dependent Form if the dependent meets the criteria listed on the front of the form.
• Adoption: Copy of the adoption placement letter on the adoption agency's letterhead, including:
  • Name(s) of adoptive parents
  • Name of the adopted child
  • Date the child was placed in the home

• Grandchild: Copy of Court Guardianship Appointment
  • If the grandchild is a dependent of a dependent under age 19, a copy of the grandchild’s certified (Long Form) birth certificate

Adoption verification and grandchild verification information can be obtained by contacting the adoption agency used or the Clerk of Court’s office in the town in which the event occurred

Additional Required Documents for Retirees and Survivors

If you and/or your spouse are eligible for Medicare, you will need to:

• Indicate your Medicare claim number on your GIC enrollment form for you and your spouse.

If you and/or your spouse are over age 65 and Medicare eligible, but not enrolled in Medicare, you will need to:

• Enroll in Medicare Part A and Part B with Social Security between January 1 and March 31.
• Enroll in a GIC Medicare plan during the GIC's spring Annual Enrollment.

If you and/or your spouse are over age 65 and not eligible for Medicare you will need the following documentation:

• Social Security Denial Letter stating that you and/or your spouse are not eligible for Medicare Part A for free.