Banyan Administrators Customer Service Form
Contact Name
*
First Name
Last Name
Contact Email
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Confirmation Email
example@example.com
Add Co-requestor? This person will receive status updates relating to this case submission.
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Co-Requestor Name
First Name
Last Name
Co-requestor Email
example@example.com
I am a:
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Employee/Subscriber/COBRA Participant
Employer/Firm Administrator
Broker/Producer
Other
Your Company Name
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6 Digit Client Code (not required)
Case Reason
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Please Select
Billing/Invoice
Claim or Find a Provider Assistance
COBRA/CalCOBRA
Enrollment/Eligibility/ID Cards
Firm/Broker Update
New Group Quoting/Proposal
New Group Processing Inquiry
Renewal/Open Enrollment Inquiry
All Other Inquiries
Subject
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Request Details
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Day
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