Group Information Request
Group Information Request
I do not know my:
*
Group Name
Group Number
Employer Name
*
Name
Name
*
First
Last
Date of Birth
Date of Birth
*
/
MM
/
DD
YYYY
Email
*
Email Consent
*
Email Consent
I authorize email communications between myself and BeniComp regarding BeniComp policies such as application, enrollment, and claims communications. I also understand that I may withdraw my consent to communicate via email at any time.