This form is used to notify the State of Michigan of a qualifying event and the name(s) and address(es) of family members who will be removed from insurances. Retain a copy for your records. EMPLOYEES ONLYreturn the completed form to MI HR SERVICE CENTER or to your Human Resource Office.RETIREESreturn the completed form to Office of Retirement Services, P.O. BOX 30171, LANSING, MI 48909.
Instructions: If this form is returned in a timely manner, the information will be used to notify the family members of their rights to continue insurance coverage(s). Please complete the top portion of this form and either Section I if you are recently divorced, or Section II if you have a dependent child no longer eligible. A portion of this information is protected by federal privacy laws and/or state confidentiality requirements.