Download Forms

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.
Get Acrobat Reader free software and technical support


Credit card forms
Equipment purchase (PDF:180 KB)
Order supplies
Data security compliance forms


Health insurance forms
Model Letter of Creditable Coverage
Member claims and coordination of benefits
Pay insurance premiums through automatic account deduction (PDF: 37 KB)


Dental insurance forms
Dental eligibility enrollment/update (PDF: 76 KB)
Retailers Insurance Company Dental Plan group underwriting roster (PDF: 69 KB)
Pay insurance premiums through automatic account deduction (PDF: 28 KB)


Vision Insurance forms
Group Underwriting(PDF: 147 KB)
Eligibility Enrollment Form (PDF: 102 KB)
Employer Application (PDF: 164 KB)


Life and disability insurance forms
Short term disabilty (PDF: 49 KB)
Life insurance (PDF: 106KB)
Member participation (PDF: 221 KB)
Evidence of insurability (PDF: 233 KB)
Pay insurance premiums through automatic account deduction (PDF: 28 KB)


Retailers Insurance Company forms
Employer's basic report of injury (PDF: 516 KB)
Short form accident report (PDF: 94 KB)
Payroll worksheet (PDF: 76 KB)
Authorization to furnish medical information (PDF: 96 KB)


Life & Disability

Powered by: Easyfish Marketing

Michigan Retailers Services, Inc. is a registered ISO/MSP of Synovus Bank, Columbus, Georgia