Get Change Request Form Rev. 01/07 - Benefitstore.net - Benefitstore

Filling out the Change Request Form is an important step for users seeking modifications to their benefits. This guide provides clear and detailed directions on how to effectively complete each section of the form to ensure a smooth process.

Follow the steps to accurately complete the Change Request Form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. In Section A, enter the required Group Name and Account Number. Ensure both fields are filled out accurately as they are essential for processing your change.
3. Move to Section B to provide information about the eligible employee or the person applying for coverage. Include their Last Name, First Name, and Social Security Number.
4. Indicate whether you are adding employee or personal coverage, selecting options such as New Employee, Part-time to Full-time, or Loss of Coverage. Provide the relevant documentation if necessary.
5. Fill in the Employee’s Date of Hire and their Hours Worked Per Week, as this information determines coverage dates.
6. If adding dependent coverage, specify the reason for the change like Birth, Marriage, or Loss of Coverage, including any required proof.
7. List policy types, such as Dental, Vision, or Health, and provide the Birth Date and Sex of the eligible employee.
8. In the section regarding dependent coverage, indicate whether there are dependent children and provide their details for adding or deleting dependents.
9. Complete the termination sections if applicable, providing reasons such as Termination of Employment, Retirement, or Divorce.
10. Enter the Effective Date for enrollment, termination, or changes to ensure accurate processing.
11. Review the Plan Type options to specify between Voluntary or Non-Voluntary plans, and fill in the relevant information.
12. Provide your mailing address, home phone, and email in the designated fields.
13. Finally, sign and date the form at the bottom to validate your changes. Make sure to keep a copy of the completed form for your records.

Complete the Change Request Form online to manage your benefits effectively.