Connecture Service Request Form

Connecture Service Request Form
This form is used to initiate a "ticket" for escalated support in regard to the Connecture online enrollment tool.

PLEASE FILL OUT THIS FORM ONLY AFTER ATTEMPTING TO SELF-DIAGNOSE AND TROUBLESHOOT THE ISSUE YOURSELF IN ACCORDANCE WITH OUR STANDARD OPERATING PROCEDURES!
Name of Person Submitting Request:*

First NameLast Name
Email Address:*
example@example.com
Name of User*

First NameLast Name
What type of issue/concern is this?*

Site Access / LoginCannot locate a record / enrollmentPlans in area not displayingScope of AppointmentQuotingOther
Have you referenced Page 3 of the User Guide?*

YesNo
Have you referenced Page 5 of the User Guide?*

YesNo
Have you referenced Pages 6 and 15 of the User Guide?*

YesNo
Have you referenced Pages 7-10 of the User Guide?*

YesNo
Have you referenced Pages 16 and 18 of the User Guide?*

YesNo
Have you attempted to diagnose and troubleshoot the issue yourself?*

YesNo
Please enter any additional information to help us resolve the issue:
Should be Empty: