Enrollment Checklist Form

The Form

The MPI Enrollment Checklist Form can be found on the MPI website.

This form must be filled out by all applicants!!

This form has three pages – the enrollment checklist, the application for coverage of a dependent child, and the Card Form. Each page is pictured and described below. Click on the page image for a larger view, but you should access the form using the link above.

Enrollment Checklist_Page_1

The checklist is very helpful as it describes which forms you must submit depending on who you are interested in covering under MPI. You should print this form and refer to it during your application process.

Enrollment Checklist_Page_2

This page is the application for a child dependent to be included in MPI. This page will need to be filled out for each child dependent you wish to cover. It asks for information about the child in the form of a check list, as well as describes what forms will have to be returned along with the application in order for your child dependent to be included.

Enrollment Checklist_Page_3

This page MUST be returned with your application. All people you intend to include in your MPI participation must be included on the form. This form also designates your beneficiaries for the life insurance portion of your MPI participation.

Fill out your information in the section at the top of the page above the first green line. In the next section, list your spouse or same-sex domestic partner’s information. In the next three sections, list any dependent children you wish to add where their information is pertinent (your biological children under 19 years old, your non-biological children under 19 (ie. adopted, step, etc.), and any children between 19 and 23).

In the bottom sections of the page, list your beneficiaries for the MPI provided Life Insurance policy. Finally, be sure to sign and date the form before sending it to MPI.