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This program is administered
by the Managed Risk Medical Insurance Board (MRMIB).

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Fillable MRMIP PDF Application For FAX Submission and Initial Premium Payment

Download Adobe Reader
Acrobat Reader is required to use the Fillable MRMIP PDF Application. Acrobat Reader 8 or above is recommended. Click here to download a free copy of Adobe Acrobat Reader if you do not have the program or to upgrade to a newer version.

STEP 1 - PREPARE

Before you begin the Fillable MRMIP PDF Application, you should review the Application Checklist for information you will need to send with your application.

STEP 2 - APPLY

Complete all fields within the Fillable MRMIP PDF Application. You need to have access to a printer as you will not be able to save this PDF. Once you click the "Review and Print" button on the last page, the PDF will check to see that you entered all the required fields. If anything is missing, a message will let you know that you should correct the application to prevent delays in the processing of your application.

STEP 3 – PAY ONLINE OR THROUGH AN AUTOMATED PHONE SYSTEM

After your application successfully prints, close the PDF. You will be returned to the instruction page to make your online payment or you can make your payment through the automated phone system (1-877-564-5394). You will need the Document Control Number (DCN) from your printed Application Fax Cover Sheet. This number is 11 digits. You will be able to create a user account with your DCN on the online payment page. Payments can be made with Visa, MasterCard, or Discover Card.

DCN location on fax cover sheet.

STEP 4 – FAX SUBMISSION

Fax your completed application and required documents, including your Application Fax Cover Sheet to 1-877-430-0843.

NOTE: If you use this fillable PDF application more than once, you should close the PDF application after printing and start a new application.