Billing Change Form

Standard Insurance Company

Professional Services Employers Trust

BILLING CHANGE FORM

Please fill out the information below to add, terminate, or adjust earnings of employees on your monthly PSET invoice.

Employees’ eligibility and coverage are based on the terms in your Policy Certificate. The monthly invoice is for billing purposes only and does not determine enrollment or coverage. The Standard will verify eligibility when a claim is filed.

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.

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.

Standard Insurance Company

Professional Services Employers Trust

BILLING CHANGE FORM

1. NEW EMPLOYEE ADDITION

2. NEW EMPLOYEE ADDITION

3. NEW EMPLOYEE ADDITION

4. NEW EMPLOYEE ADDITION

5. NEW EMPLOYEE ADDITION

1. EXISTING EMPLOYEE EARNINGS CHANGE

2. EXISTING EMPLOYEE EARNINGS CHANGE

3. EXISTING EMPLOYEE EARNINGS CHANGE

4. EXISTING EMPLOYEE EARNINGS CHANGE

5. EXISTING EMPLOYEE EARNINGS CHANGE

6. EXISTING EMPLOYEE EARNINGS CHANGE

7. EXISTING EMPLOYEE EARNINGS CHANGE

8. EXISTING EMPLOYEE EARNINGS CHANGE

9. EXISTING EMPLOYEE EARNINGS CHANGE

10. EXISTING EMPLOYEE EARNINGS CHANGE

1. EMPLOYEE TERMINATION

2. EMPLOYEE TERMINATION

3. EMPLOYEE TERMINATION

4. EMPLOYEE TERMINATION

5. EMPLOYEE TERMINATION

OTHER

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.