86 South Main
Brigham City, UT 84302
435.695.2300
550 N. Main Street Suite 110
Logan, UT  84321
435.752.1351
216 East Main
Tremonton, Utah
435.257.5320
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Request Benefit Change

Type of Change
   
Full Name *  
Telephone Number *  
Email address *  
Name of Group
ID Number
Date of Birth
Current Address
City
State / Zip   
   
Subscribers Current PCP
Subscribers New PCP
   
Number of Dependants

Information for Dependant #1
Name of Changing PCP
Name of Current PCP
New Dependants PCP
   
   
I understand that completing and sending this form does not bind coverage changes, and that no such changes will be in effect unless, and until, I receive written confirmation of the changes from my insurance agent.
  Please note this is an alternative method for communicating with us. We will contact you as soon as possible.
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