02021SEGIP Find a Form340222life insurancewaive engUse this form to reinstate your state-paid life insurance coverage above $50,000.01059Reinstate Taxable Life Insurance670972Waiver340313211 Reinstate Taxable Life Insurance<custom:Link urlOnly="true" type="Component" destination="tcm:1059-670972" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/reinstate-taxable-life-insurance.pdf2025-02-27T22:32:38Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
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<![endif]-->01059Qualifying Status Change Form552184Enrollment340310Waiver340313170 Qualifying Status Change Form<custom:Link urlOnly="true" type="Component" destination="tcm:1059-552184" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/qualifying-status-change-form.pdf2022-12-16T18:50:04Z
SEGIP Find a Form340222engUse this form to change your annual HSA contribution amount.01059HSA Change in Contribution Form355416220 HSA Change in Contribution form<custom:Link urlOnly="true" type="Component" destination="tcm:1059-355416" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/hsa-contribution-change-form.pdf2018-10-10T20:26:04Z
SEGIP Find a Form340222life insurancewaive engThe value of state-paid life insurance coverage over $50,000 is taxable income. Use this form to waive any coverage above $50,000.01059Request to Waive Taxable Life Insurance Coverage351426Waiver340313210 Request to Waive Taxable Life Insurance Coverage<custom:Link urlOnly="true" type="Component" destination="tcm:1059-351426" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/taxable-life-waiver.pdf2025-02-07T02:55:48Z
SEGIP Find a Form340222eligibilitygrandchildengForm used to certify the eligibility of your grandchild.01059Grandchild Certification form351084200 Grandchild certification form<custom:Link urlOnly="true" type="Component" destination="tcm:1059-351084" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/gchild-cert.pdf2018-09-04T16:37:04Z
SEGIP Find a Form340222Foster childEligibilityeng<p xmlns="http://www.w3.org/1999/xhtml">Form used to certify the eligibility of your foster child, child by legal guardianship, or child by relative placement.</p>01059FOSTER CHILD / LEGAL GUARDIANSHIP / RELATIVE PLACEMENT Certification Form351083190 FOSTER CHILD / LEGAL GUARDIANSHIP / RELATIVE PLACEMENT Certification Form<custom:Link urlOnly="true" type="Component" destination="tcm:1059-351083" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/foster-child-cert.pdf2026-07-16T19:33:14Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormPost Retirement Applicationeng<p xmlns="http://www.w3.org/1999/xhtml">Certification form for spouses.</p>01059Spouse Certification Form341215Spouse341232180 Spouse certification form<custom:Link urlOnly="true" type="Component" destination="tcm:1059-341215" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/spouse-certification-form.pdf2025-02-13T15:25:49Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormPost Retirement Applicationeng<p xmlns="http://www.w3.org/1999/xhtml">Agencies may develop post-retirement positions to provide non-permanent employment to retirees in order to complete project work or other work of a short-term nature. Before extending an offer of a post-retirement position, state agencies must first verify that the individual meets all eligibility criteria for the position. Eligibility for compensation and benefits is determined by each individual post-retirement agreement. Individuals hired for a post-retirement position may qualify for insurance benefits, and agencies must closely review eligibility.</p>01059Post-Retirement Option341214Retiree Forms340327160 Post-Retirement Option<custom:Link urlOnly="true" type="Component" destination="tcm:1059-341214" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/enterprise-human-capital/policy/proagreementform.pdf2022-03-17T22:10:29Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormPost Retirement Applicationeng<p xmlns="http://www.w3.org/1999/xhtml">This link takes you to the BRI landing page where you'll find forms to enroll in and make changes to pre-tax spending accounts.</p>01059Pre-Tax Forms & Applications341212Retiree Forms340327Enrollment340310Pre-tax forms and applications341213150 Pre-Tax Forms & Applications<custom:Link urlOnly="true" type="Component" destination="tcm:1059-341212" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://www.benefitresource.com/state-of-minnesota/2022-03-21T14:45:13Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormPost Retirement Applicationeng<p xmlns="http://www.w3.org/1999/xhtml">For retirees age 65 and older to convert their Employee Additional Life Insurance into the 20% paid-up policy. You should include this form with your Continuation of Coverage application upon Retirement or Special Retirement.</p>01059Post Retirement Application - Optional Life Insurance (Spouse)341206Retiree Forms340327Optional Coverage Applications340316Enrollment340310140 Post Retirement Application - Optional Life Insurance (Spouse)<custom:Link urlOnly="true" type="Component" destination="tcm:1059-341206" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/documents/segip/life/MHC-43733A-1-post-retirement-spouse-app.pdf2024-01-10T16:21:50Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormPost Retirement Applicationeng<p xmlns="http://www.w3.org/1999/xhtml">For retirees age 65 and older to convert their Employee Additional Life Insurance into the 20% paid-up policy. You should include this form with your Continuation of Coverage application upon Retirement or Special Retirement.</p>01059Post Retirement Application - 65 and older341193Retiree Forms340327Optional Coverage Applications340316Enrollment340310130 Post Retirement Application - 65 and older<custom:Link urlOnly="true" type="Component" destination="tcm:1059-341193" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/documents/segip/life/MHC-43733-1-over-65-retiree-app.pdf2024-01-10T16:21:35Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormPost Retirement Applicationeng<p xmlns="http://www.w3.org/1999/xhtml">Optional Life Insurance (Age 64 and Under) For retirees age 64 and under to continue their Employee Additional Life Insurance after retirement. You should include this form with your Continuation of Coverage application upon Retirement or Special Retirement.</p>01059Post Retirement Application - 64 and under340330Optional Coverage Applications340316Retiree Forms340327Enrollment340310120 Post Retirement Application - 64 and under<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340330" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/documents/segip/life/MHC-43732-1-under-65-retiree-app.pdf2024-01-10T16:21:43Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormFor early incentive retirees to indicate which coverages they want to continue after retirement. Continuation of Coverage Upon Special Retirementeng<p xmlns="http://www.w3.org/1999/xhtml">For early incentive retirees to indicate which coverages they want to continue after retirement.</p>01059Continuation of Coverage Upon Special Retirement 340329Optional Coverage Applications340316Retiree Forms340327Enrollment340310110 Continuation of Coverage Upon Special Retirement<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340329" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/retiree-contin-cov-special-frm.pdf2018-08-31T15:12:40Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormHIPAA releaseInformed Consent to Release Private Data for LTD/STD Claim Applicationseng<p xmlns="http://www.w3.org/1999/xhtml">Regular retirees indicate which coverages they want to continue after retirement.</p>01059Continuation of Coverage Upon Retirement Application340326Optional Coverage Applications340316Retiree Forms340327Enrollment340310100 Continuation of Coverage Upon Retirement<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340326" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/Continuation-of-Coverage-Upon-Retirement-Form.pdf2024-04-05T17:21:59Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormShort Term Disability Claim flyereng<p xmlns="http://www.w3.org/1999/xhtml">Information on how to start a short-term disability claim.</p>01059Short Term Disability Claim340323Optional Coverage Applications340316080 Short Term Disability Claim<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340323" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://www.metlife.com/info/state-of-minnesota/benefits/short-term-disability-insurance/2025-03-19T18:13:37Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormLong Term Disability Claim Applicationeng<p xmlns="http://www.w3.org/1999/xhtml">Begin a long-term disability claim.</p>01059Long Term Disability Claim340318Optional Coverage Applications340316070 Long Term Disability Claim Application<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340318" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://www.metlife.com/info/state-of-minnesota/benefits/long-term-disability-insurance/2026-04-07T15:56:04Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormManager's Income Protection Plan Applicationeng<p xmlns="http://www.w3.org/1999/xhtml">To change the Managerial Life plan option and/or change the elimination period of the Income Protection Plan.</p>01059Manager's Income Protection Plan Application340317Optional Coverage Applications340316060 Manager's Income Protection Plan Application<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340317" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/mgrs-ipp-form.pdf2018-09-04T13:47:46Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a Formoptional coverageeng<p xmlns="http://www.w3.org/1999/xhtml">Change your Employee Additional Life, Employee and Spouse AD&D, Spouse and Child Life, and Short Term, and Long Term Disability coverage.</p>01059Optional Life and Disability Insurance Application340315Optional Coverage Applications340316050 Optional Coverage<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340315" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/optional-application.pdf2026-05-22T19:24:20Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormwaiverPre-Tax Health & Dental Premium Account (HDPA) Change in Participationeng<p xmlns="http://www.w3.org/1999/xhtml"><!--[if gte mso 9]><xml>
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UnhideWhenUsed="true" QFormat="true" Name="heading 3"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 4"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 5"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 6"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 7"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 8"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="heading 9"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index 9"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
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<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 2"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 3"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 4"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 5"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 6"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 7"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 8"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" Name="toc 9"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="header"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footer"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="index heading"/>
<w:LsdException Locked="false" Priority="35" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of figures"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="envelope address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="footnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="1" SemiHidden="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
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<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
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<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
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<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
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<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
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<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
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<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
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<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
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<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
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<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
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<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
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<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
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<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
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<![endif]--></p>01059Pre-Tax Health & Dental Premium Account (HDPA) Change in Participation340314Enrollment/waiver340221040 Pre-Tax Health & Dental Premium Account (HDPA) Change in Participation<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340314" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/hdpa-change-form.pdf2018-05-30T21:07:05Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a Formwaivereng<p xmlns="http://www.w3.org/1999/xhtml">To waive medical insurance coverage because you are covered under another qualified plan or policy.</p>01059Waiver of Medical Coverage340311Waiver340313030 Waiver of Medical Coverage<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340311" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/Waiver_of_medical_coverage_form.pdf2018-10-26T19:26:04Z
SEGIP Find a Form340222Forms that help you access benefits administered by the State employees group insurance program (SEGIP).
SEGIP Find a FormFind a formadd a babyadd a spousemarriagedivorceadd dependenteng<span style="font-size:11.0pt;mso-bidi-font-size:10.0pt; line-height:112%;font-family:"Calibri",sans-serif;mso-fareast-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman";mso-ansi-language:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA" xmlns="http://www.w3.org/1999/xhtml">Use this application to change insurance coverage. Add/drop dependents to medical and dental coverage outside open enrollment when you have a qualifying life event.</span>
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<![endif]-->01059A Qualifying Status Change340223Enrollment340310Waiver340313010 A Qualifying Status Change<custom:Link urlOnly="true" type="Component" destination="tcm:1059-340223" templateURI="tcm:0-0-0" origin="tcm:0-0-0" />https://mn.gov/mmb-stat/segip/doc/qualifying-status-change-form.pdf2025-01-10T21:53:15Z