Standard Insurance Company Professional Services Employers Trust 206.236.6480 Tel

BILLING CHANGE FORM

New employees and increases in coverage may be subject to eligibility/Evidence Of Insurability requirements. An enrollment form is required and should be kept on file by you for all contributory and life coverages. Please consult your Group Policy Certificate.

Please submit changes by the 20th of the month — changes submitted after the 20th may not be reflected in the following month’s billing statement. Please reach out to ben@profbci.com with questions regarding this form.