Worker Benefits, LLC


	Questions / Comments



	Billing Questions



	Claims Questions



	Coverage Changes



	COBRA Questions



	Get Financial Planning Info



	Supplies Requests

Name:		Phone:
Fax:		E-mail:
Group Name:		Group Number:
Employee Name:		Employee ID#:
Eff. Term. Date:		Reason:

Enrollment / New Hire

Fax enrollment form for processing.
*Note: Please refer to the Employee Eligibility Page to confirm that enrollment is possible.

Please cancel the above employee from my group plan

Coverage change for an existing employee

Please call to confirm that changes can be made.
Fax Coverage Change Form / Enrollment form to us for processing.
*Note: There must be a qualifying event in order to make changes or add dependents onto a policy (i.e. birth, adoption, marriage, spouse lost other coverage, etc.). Please refer to your Employee Eligibility Page to confirm that changes can be made.

New employee has not received his cards

Call to confirm enrollment has been processed.
Call to confirm employee's address.

Please get back to me on the following issue: