Assistance Request Form

1
Company Name* This field is required.
2
Your Name* This field is required.Person Submitting Request
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Phone Number
Area Code
Phone Number
5
Please select your support categoryIf you select 'other' please include notes in the 'additional information' section on the next screen.
Please Select
Please Select
Submit a QLE (Qualifying Life Event)
Request Cancellation of Coverage
Billing or Payroll Deductions
Employee Enrollment Issues
Technical Support (Zorro)
Policy Questions on behalf of an Employee
Communications (Emails / Mi-Benefits Hub)
Process Questions (OE, New Hire's QLE, Drops/Adds/Terms)
Other
6
Additional InformationPlease provide a detailed request for assistance.
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: