MNsure Account Request Form

This form is used to verify your identity so that you can create an online account on MNsure.org. Please only use this form if you are not able to create an account online.

Account Request Form - English (PDF)

Translated Account Request Form:

• Daim Ntawv Thov Tsim Tus Account (Hmong) (PDF)
• Foomka Codsiga Akoonka (Somali) (PDF)
• Formulario de solicitud de cuenta (Spanish (PDF)
• Бланк запроса учётной записи (Russian) (PDF)
• Đơn Yêu Cầu Tài Khoản (Vietnamese) (PDF)