Request Assistance from a Benefits Advisor

* Denotes required information.
OMB Control Number: 1210-0146 Exp. Date: 10/31/2017

You are requesting assistance with:

Please check all below that apply

Which type of plan is this request for?

Other Information and Comments

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

  • efforts you have made to contact the plan administrator or employer to resolve the problem.
  • how you believe your issue should be resolved and why
  • (if related to pension benefit claims) the employee's date of birth and dates of employment
  • (if related to health claims) date(s) of service, amount(s) of the claim(s)
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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.
Invalid employer/plan official name.
Invalid employer/plan official zip code. Invalid employer/plan official zip code postfix.
Invalid telephone number. Ext:
Invalid telephone number. Ext:

Contact Person

Invalid first name.
Invalid last name.

Your Information

Invalid first name.
Invalid last name.
Invalid zip code.
Invalid telephone number. Invalid primary phone type selection. Ext:
Invalid telephone number. Invalid alternate phone type selection. Ext:
*Note: e-mail address is not required; however if not provided the Department will not be able to contact you by e-mail.

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.

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.