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Get MA MassMutual RS-35645-00 2017-2024

Ll MassMutual s Customer Service Center 1-800-854-0647 Do not use this Form to: complete your initial Plan enrollment. Fax 1-800-220-2913 Online www.massmutual.com/corp MassMutual will not process this form until it is received in good order. Please see the Important Information Section for information on "Good Order" requirements. Section A - Plan Information Plan ID Plan Name Plan Contact Daytime Phone Number Section B - Participant Information Change Name Participant Name Chan.

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