Cunnington & Associates - Request Benefit Change

Specialty Programs

2240 West Everest Lane, Ste 100
Meridian, ID 83646
Tel: 208.672.6180
Fax: 208.375.8280
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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.