Does this Employee have other medical insurance coverage?
List the names of each eligible dependents to be covered (click here for dependent criteria).
Dependent #1
Does this Dependent have other medical insurance coverage?
Two (2) consecutive printed payroll stubs issued within the last two (2) pay periods, a payroll ledger, an employer’s quarterly wage/tax report, or a letter from an attorney or certified public accountant listing employees, number of hours worked, and hourly rate. Voided checks are not acceptable.
Picture Identification
State of Michigan driver’s license or State of Michigan identification card
Spouse
If enrolling a spouse, upload copy of a marriage certificate
Dependent
If enrolling a dependent Upload a birth certificate, adoption certificate, or court ordered document of legal custody must accompany the application
I ACCEPT
By selecting the “I Accept” button, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
The undersigned represents and warrants that he/she has been authorized to execute this subscriber application and make the foregoing certifications on behalf of the employer, has been provided a copy and has read, understands and agrees to the conditions listed here.
