Group Contact Change Form
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2GROUP CONTACT CHANGE FORM
Group Information
Group Name: ____________________________________________________________________________________
SelectAccount Group #: ____________________________________________________________________________
General Information Change:
New Group Name: ____________________________________________________________________________
New Address: _________________________________________________________________________________
Street
City
State
Zip
Contact Information Change
Add new contact:
Name: ______________________________________________________________ Phone:_____________________
Fax: _______________________________ Email: ______________________________________________________
New Contact is (select one):
Primary contact
The primary contact receives all general communication, has the ability to add or remove additional contacts, and
has the Admin role on the Group Online Service Center.
Additional contact
I want to give the new Additional Contact access to the following (select all that apply):
Claim reimbursement payment email:
Yes
No
(Automated email notification that claim payment billing information is available online)
Administrative fees email:
Yes
No
(Automated email notification that the fee billing information is available online)
Payment and enrollment file load confirmations:
Yes
No
(Email confirmation for payroll and enrollment files uploads)
Access to the Online Group Service Center:
Edit Access
View Access
No Access
(Primary contact is assigned the Admin role automatically)
Change to Existing Contact Security / Inactivate
Contact name: ____________________________________________________________________________________
I want to change security for this contact as follows:
Inactivate
Change to Edit access for the Online Group Service Center and remain as an Additional Contact.
F9333R14 (03/15)
MII Life, Inc. d.b.a SelectAccount
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Parent category: Business