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Forms and Publications

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Service Credit

Application for Military Leave of Absence Credit (R0717G)
Upon returning from a military leave of absence (which interrupts your state of Michigan employment), complete this form to request service credit and employer contributions to your Defined Contribution Retirement Plan during active duty military service performed while a state of Michigan employee.


Insurance Eligibility Notice (R0517G)
Submit this document about three months before you (or your dependents) meet the insurance eligibility requirements and after you've notified your employer of your intent to terminate from state employment.

Insurance Enrollment/Change Request for State Defined Contribution Participants (R0752G)
Use this form to enroll in the retirement system insurance plans; change from one health plan to another; or add, delete, or change a name for anyone on your existing insurance coverage. Also use this form to notify ORS if you or any of your covered dependents become eligible for Medicare or other health, dental, vision, or prescription group insurance coverage.

Health, Dental, Vision, and Life Insurance Options (R0423GH)
This document outlines the insurance options available to participants of the State Employees' Retirement Systems. Please read it carefully as you make decisions about your continued insurance coverage.

Insurance Rates (R0749G) 
This form provides you with basic information about current health, dental, and vision insurance rates.

Life Insurance Beneficiary Form (R0782GHB)
This form is used to designate your primary and secondary beneficiaries for your life insurance.

Health Reimbursement Account (HRA) Information Sheet (R1047G)
This sheet provides information about the HRA tax-advantaged health savings plan.

Health Reimbursement Account (HRA) Claim Form (R1042G)
This form is used to submit HRA claims to our office.

Health Reimbursement Account (HRA) HIPAA Privacy Notice (R1054G)
This notice explains how medical information about you may be used or disclosed.

Release Authorization

Release Of Information Authorization (R3488CGHBD)  
If you need to request a copy of documents located in your account, please complete and submit this form.


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