Get Mi R0452g 2022-2025

The MI R0452G form is essential for state retirees seeking to enroll in or change their health insurance coverage. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully fill out the MI R0452G form.

1. Click the ‘Get Form’ button to access the MI R0452G online. This will allow you to view the form and begin the completion process.
2. Fill in your personal information in the designated fields. This includes your name (last, first, middle initial), member ID or social security number, phone number, and physical address. Ensure that your physical address is not a P.O. Box and includes the county of residence, city, state, and ZIP code.
3. Provide your email address. This is important for any correspondence related to your application.
4. In Section I, mark the box for the insurance plans you wish to enroll in. Indicate who you are enrolling (yourself, spouse, or child) and specify the desired effective date. Remember that effective dates are usually the first of the month.
5. For health plans, make selections from the options provided, such as Blue Cross Blue Shield of Michigan (BCBSM) or a Health Maintenance Organization (HMO). You can choose plans with or without prescription drug coverage.
6. Complete your and your dependents’ information if you are enrolling them. You will need to provide proof documents for each dependent, such as birth certificates or marriage certificates.
7. Indicate if you or any dependents have other insurance coverage, including Medicare. Fill out the necessary fields regarding other policies, such as policy numbers and effective dates.
8. If you need to cancel insurance coverage, provide the names and relevant details of individuals whose coverage you wish to terminate.
9. If applicable, request a name or address change in Section III. Include the new name, physical address, and any supporting documentation.
10. Review the information you have entered for accuracy. Once confirmed, sign and date the form in Section IV to certify the correctness of the provided information.
11. Save the changes, and decide whether to download, print, or share the completed form. Ensure it is returned to the Michigan Office of Retirement Services as instructed.

Ensure you complete the MI R0452G form online for a seamless insurance enrollment or change process.