Pub. No. 8460 | Rev. 8/2023
Michigan Department of Insurance and Financial Services | 833-ASK-DIFS | Michigan.gov/DIFS
Sample Qualified Health Coverage Documentation
Michigan’s auto insurance law allows individuals who have Qualified Health Coverage (QHC) to make
certain choices regarding their auto no-fault insurance coverage. If you would like to opt out of or exclude
Personal Injury Protection (PIP) medical coverage from your auto insurance policy, your auto insurer will
require proof of QHC to ensure you have medical coverage in the event of auto accident injuries.
Consumers should contact their health insurer or employer to receive QHC documentation. This sample
notice can be used by health insurers or employers to provide confirmation of current QHC to consumers.
Health insurers or employers may also create their own QHC documentation letter that complies with
Michigan Department of Insurance and Financial Services’ Bulletin 2023-17-INS.
Qualified Health Coverage
The coverage provided to you and eligible individuals by _____________________________ is “Qualified
Health Coverage” as defined in MCL 500.3107d(7)(b)(i) for purposes of the Michigan Auto No-Fault Law.
“Qualified Health Coverage” means your health coverage:
• Does not exclude or limit coverage for motor vehicle accidents; and
• Has an annual deductible of $6,579.00 or less per covered individual.
Full name(s) and date(s) of birth of all individuals covered by policy:
Name: ________________________________________ DOB: __________
Name: ________________________________________ DOB: __________
Name: ________________________________________ DOB: __________
Name: ________________________________________ DOB: __________
Name: ________________________________________ DOB: __________
Name: ________________________________________ DOB: __________
Name: ________________________________________ DOB: __________
Health Insurer or Health Plan Signature:
_____________________________________________________ Date: __________
