Enrollment Application – Please confirm eligibility with your employer before enrolling yourself or a dependent in your HMAA health plan.

View our health plans and administrative procedures for more information. For further assistance, contact Enrollments.

Request to Enroll

Employers may use this form to submit Enrollment Applications and/or supporting documentation for Qualifying Events (e.g., birth or marriage certificate).

If you are not the authorized contact, please obtain authorization from him/her to submit this request.

For assistance, contact Enrollments.

  • For assistance, contact Enrollments.
  • A confirmation email will be sent to this address.
  • A confirmation email will be sent to this address.
  • Required: Enrollment Application, supporting documentation for Qualifying Event, etc.
    Filling in and submitting the fields above, without attaching a supporting document, does not constitute an enrollment. Files must be in PDF. Other formats will not be accepted.
    Drop files here or
    Accepted file types: pdf, Max. file size: 2 MB, Max. files: 2.
    • This field is for validation purposes and should be left unchanged.