2023 EB Payment Discrepancy Form

Employee Benefits Invoice Payment Discrepancy Form

The payment of an amount different from the invoice is strongly discouraged unless there is an error on the EB Invoice.

Please remember payroll reports may differ from the invoice total due to employees/retirees whose changes were not submitted or submitted after the bill was processed.

The EB monthly invoice is based on the information as of the billing date (usually the 15th of each month).

Member City/Town*
Your name*
Your email*
Invoice Date*

MonthDayYear
Must always be the first day of the month
The invoice date is found at the top of the summary page (first page of the invoice) and is always the first day of the month. Click on the arrow below to see a sample invoice.

Click the arrow to see a sample invoive with the fields marked

Amount of your invoice*
Employee Name*
Description of Billing Error*
Adj Amount*
Adjusted Total
Payment Amount*
Difference
If $0 this field will be blank
If the "Difference" field above displays an amount, please explain that difference.
When you submit this form you will receive the same notice as MMIA. The form is not password-protected so please do not include social security numbers, dates of birth, or other private information. If you need to send protected health information please use the secure upload link for employee benefits.
EB Email
hidden
Inv Amt
Adj 1
Adj 2
Adj 3
Adj 4
Adj 5
Adj 6
Adj 7
Adj 8
Adj total
pmt amt
diff
Should be Empty:

Employee Benefits Invoice Payment Discrepancy Form