Forms

Choose this option if you are enrolling for the first time such as:

• A newly hired employee,
• An employee who recently became benefit-eligible
• The spouse of a retiree or employee who wants to join the plan
• The surviving spouse of a deceased employee, or an eligible elected official
• Updating contact information
• Requesting replacement ID cards

Or if you are removing all MMIA EB coverages for an employee/retiree and all spouse/dependents covered under their benefits.

     Benefit Enrollment & Termination Form

Choose this option if you are an existing employee or retiree and you want to make a change to your benefits such as:

• Updating contact information
• Requesting replacement ID cards
• Adding or removing coverage or adding dependents
• Removing dependents - This can be done at any time for any reason.
• Letting your city and MMIA EB know you are retiring and would like to retain some of all of your current MMIA coverages
• Letting your city and MMIA EB know you or someone on your plan has become Medicare‐eligible

      Change Enrollment Form

• Voluntary Term Life Enrollment (PDF)
• Basic & Voluntary Life Beneficiary Form (PDF)
• Evidence of Insurability (PDF)
• Affidavit to Enroll Domestic Partner (PDF)
• Common Law Marriage Affidavit (PDF)

Use the following forms to manually request claim reimbursement or visit the vendor’s website to do it online.

• Medical Claim Reimbursement PDF Form Vendor: www.AskAllegiance.com
• Vision Out-of-Network Claim Reimbursement PDF Form Vendor: www.VSP.com
• Proact Prescription Reimbursement PDF Form Vendor: https://secure.ProActRX.com/
• Ridgeway Mail Order Prescription PDF FormVendor: https://Ridgeway.Pharmacy/
• CRx formerly known as MMIA Scripts (web ID: MMIA) https://www.crxintl.com/
• Authorization for Release of Information Form (PDF)