Change Employee Health Benefits

1
Your Contact Information* This field is required.In case we have questions
Name
Email
2
Employer* This field is required.What is your company name?
3
Reason for Change* This field is required.For enrollment changes, please use Onboarding or Termination forms.
Compensation Change
New Address
New Employee/Dependent Name
New Title/Classification
Other
4
Qualifying Event Date* This field is required.Please provide date the change occurred.
Do not use coverage effective date; plan rules will calculate based on QE date.
Year
Month
Day
5
Employee Basics* This field is required.Please tell us who this is
Employee Name
Last 4 of SSN
6
Change Details* This field is required.Please provide the relevant information here.
To update compensation for multiple employees, please contact us separately to submit in bulk via spreadsheet
7
Upload Forms or Supporting DocumentsOnly if needed
Drag and drop files here
Select files to upload
Cancelof
8
File Uploaded?Log in to Jotform to securely retrieve uploaded files
Should be Empty: