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.
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Credit card forms
Equipment purchase (PDF:437 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: 28 KB)

Dental insurance forms
Dental eligibility enrollment/update (PDF: 76 KB)
Retailers Mutual Insurance Company Dental Plan group underwriting roster (PDF: 70 KB)
Dental claim
Pay insurance premiums through automatic account deduction (PDF: 28 KB)

Vision Insurance forms
Group Underwriting(PDF: 66 KB)
Eligibility Enrollment Form (PDF: 86 KB)
Employer Application (PDF: 160 KB)

Life and disability insurance forms
Short term disabilty (PDF: 52 KB)
Life insurance (PDF: 64KB)
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: 94 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)