PDF Insurance Enrollment Change Request - State of Michigan 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields, including your name, member ID or SSN, physical address (note that a P.O. Box is not acceptable), county of residence, email address, and phone number.
3. In Section I, mark the appropriate boxes for the insurance plans you wish to enroll in. Specify who you want covered (yourself, spouse, or children) and indicate the desired effective date for your insurances.
4. Complete the details for each dependent you wish to enroll. Ensure you provide necessary proofs as required by the form instructions.
5. If canceling coverage, fill out Section II with the names and qualifying events for those being removed from coverage.
6. For any name or address changes, complete Section III with your new information and attach legal documentation if applicable.
7. Finally, sign Section IV to certify that all provided information is accurate before submitting your completed form.

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