Benefits Enrollment Issue Report Form
Report any problems encountered during your benefits enrollment. Please provide as much detail as possible so we can assist you promptly.
Full Name
*
First Name
Last Name
Work Email Address
*
example@example.com
Department or Team
Which benefit(s) are affected?
*
Medical Insurance
Dental Insurance
Vision Insurance
Flexible Spending Account (FSA)
Health Savings Account (HSA)
Life Insurance
Disability Insurance
Other
Date the issue was noticed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please describe the issue in detail
*
Have you attempted any troubleshooting steps?
Yes
No
Please upload any supporting documents (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred method of contact for follow-up
Email
Phone
Phone Number (if you prefer phone contact)
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Issue
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