Client Service Form

	Client Service Form

ENROLLMENTS, TERMINATIONS & COVERAGE CHANGES

First Name:

Last Name:

Email Address:

Phone:

Group Name:

Group Number:

Employee Name:

Employee ID#:

Eff. Term. Date:

Reason:

Enrollment/New Hire
Fax enrollment form for processing.
*Note: Please refer to the Employee Eligibility Page to confirm that enrollment is possible.

Please cancel the above employee from my group plan

Coverage change for an existing employee
Please call to confirm that changes can be made.
Fax Coverage Change Form/Enrollment form to us for processing.
*Note: There must be a qualifying event in order to make changes or add dependents onto a policy (i.e. birth adoption marriage spouse lost other coverage etc.).
Please refer to your Employee Eligibility Page to confirm that changes can be made.

New employee has not received his cards
Call to confirm enrollment has been processed.
Call to confirm employee's address.

Please get back to me on the following issue:

Do not enter anything in this field: