Fillable Change Request Form (Page 2 of 2) in pdf

SPECIAL INSTRUCTIONS

(Please print)

BMLL Billing Number: Please enter your BenefitMall Billing number. This can be found on

your monthly invoice.

Effective Date of Change: Enter date (MM/YY/DD)

Team Number: Assigned by BenefitMall. Enter if known

Carrier Group Number: Enter if known

Employer with 20 or more employees? Mark appropriate box.

COVERAGE CHANGES: Select box according to Change Type.

Name Change: Enter complete old and new names. Last name, First name, Middle initial

Address Change: Enter new address only.

Beneficiary Change: For Life insurance purposes only.

Cancel Coverage(s): To cancel coverage, mark box titled “Cancel Coverage,” check the line

of coverage cancelling and include the Last Day Worked (MM/YY/DD). Check the line of

coverage/type box(es) in the section below. Checking the “Cancel Coverage” box

will cancel coverage for any dependents currently covered.

Notice of cancellation for group health (medical, dental and CareFirst BCBS vision) must be

received by the last day of the month prior to the requested termination date of coverage. For

example, a request to terminate coverage effective 8/1 must be received by BenefitMall no later

than 7/31. If notification is received after the requested date of change, a charge may be

applied up to and including the date the late notice is received. This rule also applies when

removing a dependent from an active membership (i.e., spouse, overage dependent child). Fax

transmissions received after 3:00 p.m. are counted as arriving on the next business day.

CHANGE IN CURRENT COVERAGE -or- EMPLOYEE TERMINATION OF COVERAGE

Change Coverage: To change coverage, mark box provided with the old coverage (“From”)

and the new coverage (“To”). If changing to a coverage that includes dependents, enter

dependent information in the boxes at the bottom of the form For medical coverage, the social

security numbers are required. Coverage changes may also require completion of a health

questionnaire or other pertinent information. For “OTHER” coverage, provide the dollar amount

changing From/To (if applicable).

Example:

From: Medical/Employee Only

To: Medical/Family

From: Dental Employee & Spouse

To: Dental/Family

Qualifying Event (Reason for Change): Enter date the event took place (MM/YY/DD) and

select the event type. If “Other,” mark box and write in Qualifying Event. Documentation may be

required. Please refer to your carrier guidelines for more information.

Medicare Information: Enter Medicare information and submit a copy of your Medicare card

along with this form.

Dependent Information: If adding coverage for dependents, complete all the information in the

space provided, including the name of the Primary Care Physician, OB/GYN and/or Dentist (if

applicable).

Signature:

Employee and Employer must sign and date the form.

Rev. 9/08

Change Request Form Page 2

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