Forms

The following forms may be used to enroll in or make changes to your coverage during qualifying enrollment periods. Please submit ALL forms to your city or town representative. For questions, contact your city or town representative or the MMIA Employee Benefits staff at 1-800-635-3089 option 4.

Enrollments and Change Forms

Claims Reimbursement and Mail Order Forms

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