Completed request forms must be received at least 21 days in advance of event date.
To get started:
1. Download/save this form to your desktop. Use requesting agency and date of event in the file name, eg: mmb-08-16-2022.pdf
2. Open the downloaded/saved form and complete.
3. Save your changes.
4. Email completed form as an attachment to Employee Insurance attn: Lynn Burwell (lynn.burwell@state.mn.us) for review. We will use the provided contact information to confirm prior to the event.
Contact Employee Insurance/SEGIP at (651) 355-0100 if your event has not been confirmed within seven days or with any questions.
