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

• Benefit Enrollment, Termination or Change Form - Printable Version (PDF)
• Benefit Enrollment, Termination or Change Form - Fillable Version (PDF)
• Voluntary Term Life Enrollment (PDF)
• Basic Life Beneficiary Form (PDF)
• Evidence of Insurability (PDF)
• Affidavit to Enroll Domestic Partner (PDF)

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.

• 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)