Explanation of Benefits Request
This form is to submit a request for help understanding statements your insurance company has sent you. Please upload ALL PAGES of statements.
Not for claim follow up
This form is not to request claim follow up actions. If you need us to follow up with your insurance on a claim, please use the Claim Follow Up request form on our website.
Name
*
First Name
Last Name
Email
*
example@example.com
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Additional comments
Please let us know any specific questions or concerns you have about the statements. Also include any information you may have received through insurance portals or phone calls with insurance. This will help us be thorough in the clarification we provide. Thank you!
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