Get Benefitmall Change Request Form - Innovative Benefit Solutions 2020-2025

Filling out the BenefitMall Change Request Form online is a straightforward process that allows users to update their benefits easily. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in your editor.
2. Enter your BenefitMall Billing Number as noted on your monthly invoice. This is necessary for tracking and processing your request.
3. Fill out the Effective Date of Change by entering the date in the format MM/DD/YY.
4. Indicate whether your employer has 20 or more employees by marking the appropriate box.
5. If updating your name, provide your previous and new last, first, and middle name.
6. If cancelling coverage, check the ‘Cancel Coverage’ box and select the specific types of coverage you wish to cancel. Include the Last Day Worked date.
7. Enter the qualifying event date and type of event that necessitates the change.
8. Neither the employee nor the employer forget to sign and date the form, as both signatures are required for completion.
9. Once all changes are made and the form is completed, you can save changes, download, print, or share the form as needed.

Complete your BenefitMall Change Request Form online today!