Customer Contact Form
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1
2Municipal Employees’ Retirement System of Michigan
1134 Municipal Way • Lansing, MI 48917
800.767.MERS (6377) • Fax: 517.703.9711
Customer Contact Form
Please print • Keep a copy for your own records
1. Municipality identification
Municipality name*
Municipality number (6 digits including reporting unit)*
This information is intended to:
Replace all contact information on file with what is provided below (also use this for new/initial contact information)
Update or add to existing information with contact information provided below
2. Address information
Primary address
Name of location*
Street*
P.O. Box
City*
State
Zip*
Alternate address 1 (if applicable)
Name of location
Street
P.O. Box
City
State
Zip
Alternate address 2 (if applicable)
Name of location
Street
P.O. Box
City
State
Zip
3. Municipal contacts
Primary contact* (one per employer)
Receives Annual Actuarial Valuation, Financial Reports, News Alerts, and other communications
Name*
Position title
E-mail*
Address:*
Phone (area code and number)*
Fax (area code and number)
Primary
Alternate 1
Alternate 2
Portal access:
Reporting Portal
Plan Details Access
ePayment
Finance contact (one per employer)
Receives Annual Actuarial Valuation, Financial Reports, News Alerts, Quarterly Statements, Invoices, Financial-specific
Communications, and Plan Details Access
Check here if same as Primary Contact
Name*
Position title
E-mail*
Address:*
Phone (area code and number)*
Fax (area code and number)
Primary
Alternate 1
Alternate 2
If applicable, please select the following online access types:
Reporting Portal
Plan Details Access
ePayment
* Required field
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Form 85 Customer Contact (version 2015-03-30)
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Parent category: Business