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BenefitMall Change Request Form - Innovative Benefit Solutions 2026
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- Click ‘Get Form’ to open the BenefitMall Change Request Form in the editor.
- Begin by entering your BMLL Billing Number and the Effective Date of Change in the designated fields. Ensure you follow the MM/DD/YYYY format for accuracy.
- Select the type of change you are requesting: Name/Address Change, Beneficiary Change, Coverage Change, or Cancel Coverage. Fill in the relevant details as prompted.
- For a Beneficiary Change, provide the names, relationships, and percentage of benefits for each beneficiary. Make sure to revoke any previous designations.
- If you are canceling coverage, check the appropriate boxes for all coverages being canceled and include your Last Day Worked along with the reason for termination.
- Complete any additional sections related to coverage changes or qualifying events by marking the appropriate boxes and providing necessary dates.
- Finally, ensure both you and your employer sign and date the form before submission to validate your request.
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