Insurance Forms

MetLife Summary Annual Reports (SAR)

Plan year ending May 31, 2016

• Sample Letter Explaining Changes to SAR and SPD (March 27, 2017)
• Plan 501 Group Life
• Plan 502 Dental and STD
• Plan 503 LTD

Summary Plan Description (SPD)

• Template
• Sample
• Sample with Notes

Enrollment/Change

• Enrollment Form – Any Coverage
• Dental and/or Vision only – Enrollment Form 
• Supplemental Life – Enrollment/Change Form
• Buy up – Life – Enrollment Form
• Insurance Change Form
• Statement of Health Form
  • MMA group #0001-#5514
  • MMA group #6100-#9999
• Statement of Health Form (Supp Life Only)
  • MMA group #0001-#5514
  • MMA group #6100-#9999

Dental

• Dental Claim Form
• Dental ID Card
• Dental Claim Customer Service Map
• Find a Dental Provider
• My Benefits Registration

Vision

• Vision Claim Form
• Vision – ID Card
• Coverage Verification
• Find a Vision Provider
• My Benefits Registration

Basic Life

• Claim Forms – Contact MMA at 517-487-8525
• Waiver of Premium – Contact MMA at 517-487-8525
• Portability of Supplemental Life Benefits to an Individual Policy
  • MMA group #0001-#5514
  • MMA group #6100-#9999
• Conversion of Group Life Benefits to an Individual Policy
  • MMA group #0001-#5514
  • MMA group #6100-#9999
• Beneficiary Designation Form
• Grief Counseling Services

Disability

• Long Term Disability – Cognitive Behavioral Therapy
• Short Term Disability Claim Form
  • MMA group #0001-#5514
  • MMA group #6100-#9999
• Long Term Disability Claim Forms
  • Employee Statement
    • MMA group #0001-#5514
    • MMA group #6100-#9999
  • Employer Statement
    • MMA group #0001-#5514
    • MMA group #6100-#9999
  • Attending Physician Statement

• Vision Plan Benefits for MMA Premium
• Vision Plan Benefits for MMA Premium Plus
• The Superior Difference 
• Out of Network Claim Form

For additional assistance, contact Kristi Peterson at kristi.peterson@versanthealth.com or 262-352-2769.

Members participating in the MMA-sponsored Blue Cross Blue Shield Program can access forms and other administrative tools for managing your health benefits on the Blue Cross Blue Shield Administration website.

• Group Customer FAQ – Coronavirus Coverage
• Enrollment and Change of Status Form

For additional assistance, contact Kelli Zussman at mma@grabenefits.com or 800-678-4456.