Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the Benefitmall Billing number in the designated field. This number can be found on your monthly invoice.
3. Input the effective date of the change using the format MM/DD/YY.
4. If applicable, enter your Team Number. This number is assigned by Benefitmall.
5. Fill in the Carrier Group number if known.
6. Indicate whether your employer has 20 or more employees by marking the appropriate box.
7. Select the type of change you are requesting by checking the corresponding box: Name/Address Change, Beneficiary Change, Coverage Change, or Cancel Coverage.
8. If you are changing the beneficiary, provide the new beneficiary's name, relationship, and percentage of benefit in the designated spaces.
9. For a name change, enter your previous name followed by your new name.
10. For an address change, input the new address in the space provided.
11. If cancelling coverage, mark the 'Cancel Coverage' box and specify the type(s) of coverage being cancelled. Include the last day worked and termination reason if applicable.
12. For coverage changes, specify the current coverage ('From') and the new coverage ('To') for each type that applies.
13. Provide a qualifying event date and select the appropriate reason for the change from the list provided.
14. Complete the Medicare information section if applicable, including the effective dates and policy number.
15. If applicable, fill in the dependent information and physician details for any dependents being added or changed.
16. Both the employee and employer must sign and date the form to certify the information is accurate and complete.
17. Once you have completed all sections, you can save changes, download, print, or share the form as needed.

Start completing your Benefitmall Change Request Form online today.