Freelancer Health Coverage Modification Form
Request changes to your freelancer health coverage. Please complete all sections accurately to ensure timely processing.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Health Coverage Plan
*
Please Select
Basic
Standard
Premium
Other
Requested Modification
*
Upgrade coverage
Downgrade coverage
Add dependents
Remove dependents
Other
Please specify details of the requested modification
*
Are you adding or removing any dependents?
*
Adding dependents
Removing dependents
No change
List dependents to add or remove (full name, relationship, date of birth)
Reason for modification request
*
Supporting Documents (if any)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit Modification Request
Submit Modification Request
Should be Empty: