STATE QUALIFIED PLANS

MICHIGAN STATE RESIDENTS

HEALTH COVERAGE TAX CREDIT (HCTC)

Call Center

1(800) 236-4782

Providing the best insurance coverage for the residents of the State of Michigan and specialize in assisting Michigan HCTC Qualified Members and their dependents.

MEDICAL, PRESCRIPTION DRUG, DENTAL & VISION BUNDLED PPO PLANS

FORMS

Enrollment Forms

BCBS Form - Medical Enrollment Form

13441A Form - IRS Enrollment Form

SAMPLE 13441A Enrollment Forms

Sample 13441-A (IRS) Enrollment Form

(RETIREE ENROLLING)

Sample 13441-A (IRS) Enrollment Form

(SINGLE PERSON ENROLLING)

Sample 13441-A (IRS) Enrollment Form

(FAMILY ENROLLING)

Sample 13441-A (IRS) Enrollment Form

(QUALIFIED FAMILY MEMBER ENROLLING)

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have

questions?

Call Us!

(844)428.2669 OR (844)HCTC-NOW