Term or Status Change

PLEASE NOTE: This form is for Terms and Changes only, no New Hires. 

NOTICE: If you do not receive confirmation of this change request within 24-48 hours, please call our Customer Satisfaction Center at 1-888-479-0490.

Employer
Employee Name
Date of Hire
SSN
Date of Birth
     
Type of Request
Date of Event (Term or Change Date)
Effective Date
Reason for Term or Change
Voluntary or Involuntary Term of Employment? (Voluntary means the employee chose to leave. Involuntary means the company let the employee go).
   
Check all that apply
     
     
Other
Additional Notes or Instructions (update employee change info here, info i.e. address):
E-Signature

Not finding what you are looking for?
Some requests are more complicated and require further discussion.

Email: receptionist@benefit-advisors.com
Phone: 888-479-0490 or contact your sales agent.