Paper qualifying event form
Download and complete a paper form if you prefer, and mail it to PO Box 1157, Pierre, SD 57501, or fax it to 605-224-0909, or email it to firstname.lastname@example.org.
Employer group administrators can use this form to notify us of a change in coverage status for an enrolled primary member or dependent.
Online form instructions:
If you have any questions, contact us at email@example.com or call 877-841-1478. We're happy to help!