Request Assistance from a Benefits Advisor

To get a Benefits Advisor to call you, submit your name, address and phone number
* Denotes required information.
OMB Control Number: 1210-0146 Exp. Date: 04/30/2027

Your Information

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Please provide more detailed information about why you are requesting assistance, such as:

Which type of plan is this request for?

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You are requesting assistance with:

Please check all below that apply

You are a:

If you are not the employee, please provide name of the employee
Selection of "Other" requires comments in the "You are a:" section.

What happens after I submit a request for assistance?

After your request for assistance is received, you will be contacted by a Benefits Advisor by the close of the second business day. You may receive a response by email; or, if the Benefits Advisor does not have enough information to completely answer your question, he or she may need to speak to you by telephone to discuss your situation. If at all possible, please include both your email address and your day-time telephone number so that we can respond to you promptly.

How will my information be used?

Your information is primarily used to respond back to you about your question or concern. We may also contact your employer, union, or plan service provider to help resolve your issue. If you do not want us to contact your employer, union, or plan service provider without speaking to you first, please indicate that in your message to us. Your information will also be logged in EBSA's tracking system so that there is a record of the question, concern, or complaint that you have brought to our attention.

Employer/Plan Contact Information

Employer/plan official type is required.
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Contact Person

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Attachments

If you have attachments you want to include with your inquiry select the appropriate button below. If you select yes, after submitting your inquiry you will receive a confirmation. Click the Exit button to be directed to the attachment upload page.

Examples of Relevant Attachments are:

  • claims
  • insurance cards or benefits statements
  • notices of potential pensions from the Social Security Administration
  • any responses received from your inquiries to the plan administrator
  • relevant portions of the plan documents or summary plan description
You must select whether or not you have attachments to include.
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Privacy InformationPaperwork Reduction Act Information EBSA 301 June 2011