Optional Spouse And Dependent Group Life Insurance Election Form
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4Department of Technology, Management & Budget
Office of Retirement Services
(800) 381-5111
P.O. Box 30171
Lansing, MI 48909-7671
Insurance Enrollment/Change Request
For Public School Retirees
MEMBER’S NAME (LAST, FIRST, M.I.)
MEMBER ID OR SSN
PHONE NUMBER
(
)
PHYSICAL ADDRESS (CANNOT BE A PO BOX)
COUNTY OF RESIDENCE
EMAIL ADDRESS
CITY, STATE, ZIP CODE
Use this form to enroll in one or more of the retirement system insurance plans, change from one health plan to
another, or add, delete, or change a name for anyone on your existing insurance coverage. Also use this form to
notify the Office of Retirement Services (ORS) if you or any of your covered dependents become eligible for other
health, prescription drug, dental, or vision insurance coverage, including Medicare if enrolling before age 65.
Section I: Enrolling In Insurances
Check the box for the provider you are selecting. You can choose either Blue Cross Blue Shield of Michigan
(BCBSM), with or without Catamaran prescription drug coverage, or
,
a Health Maintenance Organization (HMO)
which includes drug coverage. (If you are enrolling in an HMO, please contact the HMO for an application and
include it with this application.) Also check the box for dental/vision if you wish to add that insurance. Please
indicate the earliest effective date for your insurances to begin. Effective dates are always the first of the month. ORS
will determine your actual insurance effective date based on your qualifications.
Effective Date
(Check all that apply)
ENROLL
Health Plan
/01/
SELF
SPOUSE
CHILD(REN)
PARENT(S)
IF ENROLLING IN A HEALTH PLAN, PLEASE CHOOSE FROM THE FOLLOWING:
BCBSM WITH PRESCRIPTION DRUG PLAN
HMO: (PLEASE OBTAIN AND ENCLOSE A COMPLETED HMO APPLICATION).
BCBSM WITHOUT PRESCRIPTION DRUG PLAN
BCN
HAP
PRIORITY HEALTH
Effective Date
(Check all that apply)
ENROLL
Dental/Vision Plan
/01/
SELF
SPOUSE
CHILD(REN)
PARENT(S)
Complete the following information about yourself and dependents you wish to enroll. Provide proofs for any new
dependents you are adding. See the instructions for details on eligible dependents and required proofs.
If you or any of your dependents will be covered under another insurance plan, including Medicare, as of the
effective date of this coverage, indicate that additional coverage below.
Copy the Medicare information from the
Medicare card for anyone you are covering. Attach additional sheets if necessary.
SEX
ENROLLEE NAME (LAST, FIRST, MIDDLE)
SOCIAL SECURITY #
DATE OF BIRTH
M
F
OTHER DATE OF EVENT:
RELATIONSHIP:
QUALIFYING EVENT:
ADOPTION
BIRTH
MARRIAGE
MEDICARE INSURANCE COVERAGE?
MEDICARE CLAIM #
MEDICARE, EFFECTIVE DATES
PART A
PART B
Y
N (IF N, LEAVE THIS LINE BLANK)
OTHER INSURANCE COVERAGE?
POLICY #
CARRIER NAME/COVERAGE TYPE
Y
N (IF N, LEAVE THIS LINE BLANK)
R0452C (Rev. 10/2015)
*000365000000000E*
Authority: 1980 P.A. 300, as amended
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