Group Contact Change Form Page 2
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1
2File Load Confirmation Change
Change contact email address to: ___________________________________________________ FSA
HSA
Agency/Agent Affiliation Change
Change Agency To:
Agency Name: ___________________________________ Agency Code: ________________________________
Agency Address: _____________________________________________________________________________
Street
City
State
Zip
Change Agent To:
Agent Name: ___________________________________ Agent Code: ___________________________________
Agent Email: ___________________________________ Agent Phone: __________________________________
Signature
Effective Date of Change: ________________________________
_____________________________________________________________ ___________________
Group Contact Signature
Signature Date
Questions? Call Group Leader Services at (651) 662-2320 or 1-888-460-4013
Send via secured email only:
Fax to:
Mail to:
SelectAccount.documents
651-662-7247
P.O. Box 64193
866-231-0214
St. Paul, MN 55164-0193
F9333R14 (03/15)
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Parent category: Business