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.

     Benefit Enrollment 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.
• 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

Choose this option to remove all MMIA EB coverages for an employee/retiree and all spouse/dependents covered under their benefits.

      Termination Enrollment Form

• Voluntary Term Life Enrollment (PDF)
• Basic & Voluntary Life Beneficiary Form (PDF)
• Evidence of Insurability (PDF)
• Affidavit to Enroll Domestic Partner (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/
• MMIA Scripts Enrollment Packet PDF Form Vendor: www.MMIAScripts.com
• Authorization for Release of Information Form (PDF)