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Get MI R0452C 2015

Blic 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 .

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