Insurance Billing Changes Form - Minnesota Management And Budget

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INSURANCE BILLING CHANGES
Please return if making changes to Insurance Bill
DEPT SET ID: _________________
HR PROCESSING UNIT: ______________
BILLING PERIOD: ______________
EMPLOYEE NAME
EMPLOYEE ID
EFF DATE
CHANGE
(if needed)
PLEASE RETURN TO:
TOTAL PAID ON EMPLOYER BILLING REVIEW
PAGE:_______________________________
SEGIP Billing
Minnesota Management & Budget
State Employee Group Insurance Program
____________________________________________
400 Centennial
658 Cedar Street
Your Name/phone #
ST. PAUL, MN 55155
Fax:
651-296-5445
Phone: 651-355-0100
H:\USERS\SouthShare\INSURANCE_SEMA4\EIB Letters\FORMS\BILLING_FORM.doc

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