Submit an Appeal

Please complete the form below if you have an appeal related to your benefits. Provide complete information and attach any supporting documentation that can assist in making a determination. You will receive a letter via US mail once a determination is made. Please allow up to 30 days for your appeal to be processed. 

What type of appeal are you filing?:	Open Enrollment New Hire Life Event
Employee First Name:
Employee Last Name:
Employee Date of Birth:	CalendarToday
Address:
Address Line 2:
City:
ZIP code:
Email:
Phone Number:
Reason for appeal?:
Supporting Document:
Additional Supporting Document: