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Schedule Enrollment Form
Hi there, please answer the following to complete enrollment with your expert enrollment team. If at anytime you need help, reach out to teresa@mi-benefits.com for assistance.
9
Questions
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1
Full Name
First Name
Last Name
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2
Employer
Please use complete name of the company where you are employed.
COMPANY NAME
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3
Are you or any of your dependents Medicare eligible?
Choose one option.
YES
NO
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4
To enroll in Medicare, you must first enroll in Part A & Part B. A copy of your ID Card is required. Upload your file here.
Need help with enrolling in Medicare? Check out mi-benefits.com/medicare for more information.
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Max. file size
: 10.6MB
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5
With ICHRA, Medicare is better than ever! Find out more when speaking with an enrollment expert. Choose your call time here.
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6
Have you logged in to set up your Zorro account?
The Zorro platform will be your selection tool to allow you to shop your benefits. Find out more on your HUB! visit mi-benefits.com/hub
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NO
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7
Have you already selected benefits?
This can be done in the Zorro platform, check out the details on the HUB!
YES
NO
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8
That's OK. It is recommended that you complete dependent information prior to the enrollment counselor meeting in order to have enough time to make benefit decisions.
Need help with logging in and knowing what information to have ready? Visit your benefit hub at mi-benefits.com/HUB to learn more!
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9
Please select your enrollment call time below.
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