Forms
| Michigan Programmers Insurance Agency |
| 1400 Abbott Road Suite 440, East Lansing, MI 48823 Toll Free 1-800-327-1950 Fax 1-517-337-7431 |
| MPIA |
Questions Please
Call 800-327-1950
Call 800-327-1950
 |
 |
 |
 |
 |
 |
 |
 |
1. Fill in your business information.
2. Under “Type of Coverage” check Employer Sponsored Plan.
3. Next, “How many Prescription Drug Options offered under this coverage.
For most of you the answer will be 1.
4. Next, check “All Options Offered are Creditable”.
5. Insert name of person completing this form and title.
6. Insert your email address or if you prefer not to, insert noname@noisp.com.
7. Insert date and hit continue.
Our interpretation of CMS regulations is that an employee of your business must
complete the form. You cannot authorize an outside person to complete for you. If,
however, you have questions or problems with the form, please call our office at 800-
327-1950 for assistance.
| Instructions for completing on-line CMS Creditable Coverage Disclosure to CMS form. |
| (click to open form) |