Request Assistance from a Benefits Advisor

To get a Benefits Advisor to call you, submit your name, address and phone number

General Information Printable Mail-In Form Español

* Denotes required information.

OMB Control Number: 1210-0146 Exp. Date: 04/30/2027

Your Information

First Name:*

Middle Initial:

Last Name:*

Street Address:

City:

State/Zip:*

Phone Number (Business Hours):*

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Alternate phone number:

Ext

Email Address:*

Please provide more detailed information about why you are requesting assistance, such as:

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What is this request for?

Opt-out from data being included in Lost & Found

For verification purposes, please provide the last 4 digits of your social security number:*

I am the individual to whom the information applies:*

I know that if I make any representation that I know is false to obtain information from Social Security records, I could be punished by a fine or imprisonment or both:*

Health Plan (such as medical, dental, vision, etc.)

Retirement/Pension Plan (such as 401(k), defined benefit, profit sharing, etc.)

Other Benefit Plan (such as long term/short term disability, severance, life insurance, etc.)

Employer/Plan Contact Information

Type:

Employer/plan official type is required.

Name:

Address:

City:

Zip Code:

State:

Phone Number:

Ext

Alternate Phone Number:

Ext

Email:

Website:

Contact Person

Contact First Name:

Contact Middle Initial:

Contact Last Name:

Plan Contact Information previously added
Name	Last Name	First Name	Edit	Delete

Attachments

If you have attachments you want to include with your inquiry select the appropriate button below. If you select yes, after submitting your inquiry you will receive a confirmation. Click the Exit button to be directed to the attachment upload page.

Examples of Relevant Attachments are:

claims
insurance cards or benefits statements
notices of potential pensions from the Social Security Administration
any responses received from your inquiries to the plan administrator
relevant portions of the plan documents or summary plan description

You must select whether or not you have attachments to include.

Yes, I have attachments I would like to upload.

No, I do not have any attachments.

Request Assistance from a Benefits Advisor

There were some problems processing your request:

Your Information

What is this request for?

You are requesting assistance with:

Please check all below that apply

You are a:

Employer/Plan Contact Information

Contact Person

Attachments

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Request Assistance from a Benefits Advisor

There were some problems processing your request:

Your Information

What is this request for?

You are requesting assistance with:

Please check all below that apply

You are a:

Employer/Plan Contact Information

Contact Person

Attachments