Forms

City of Helena – Photo by Montana Pictures.net

The MMIA EB program now uses secure, HIPPA-compliant online forms. Choose an option below to enroll, make a change, or terminate your coverage. Once an online form is submitted, it will go to both your city/town benefit representative and the MMIA. For questions, contact your city or town representative or the MMIA Employee Benefits staff at 1-800-635-3089 option 4.

Benefit Enrollment & Termination Form

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.

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

Change Enrollment

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.
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

Other Enrollment Forms