Many of the following member forms are in PDF format. Please download,
print, fill out and mail to MRA.
To download the PDF forms, you'll need Adobe Acrobat Reader.
free software
and technical support
Credit card forms
Equipment purchase (PDF:
88 KB)
Order supplies
Health insurance forms
Model Letter of Creditable
Coverage
Member
claims and coordination of benefits
Pay insurance premiums through automatic
account deduction (PDF: 28 KB)
Dental insurance forms
Delta Dental eligibility
enrollment/update (PDF: 76 KB)
MRA MEWA Delta Dental
Plan group underwriting roster (PDF: 12 KB)
Delta Dental claim (PDF:
48 KB)
Pay insurance premiums through automatic
account deduction (PDF: 28 KB)
DeltaVision Plan forms
Group Underwriting
(PDF: 32 KB)
Eligibility Enrollment
Card (PDF: 28 KB)
Employer Application (PDF:
80 KB)
Life and disability insurance
forms
Short term disabilty
(PDF: 52 KB)
Life insurance (PDF: 64
KB)
Member participation
(PDF: 88 KB)
Evidence of insurability (PDF: 156 KB)
Pay insurance premiums through automatic
account deduction (PDF: 28 KB)
Retailers Mutual Insurance Company
forms
Employer's basic report
of injury (PDF: 516 KB)
Short form accident report
(PDF: 64 KB)
Payroll worksheet (PDF: 76 KB)
Authorization to furnish medical
information (PDF: 96 KB)
Electric Choice forms
Detroit Edison customer information
release (PDF: 36 KB)
Detroit Edison customer
information release - additional accounts (PDF: 49 KB)
