Employer Request Form
Company Name:
HR Contact Name:
HR Contact 4 Digit Pin:
Telephone:
Email:
Type of Service:
Employee Termination
Company Name/Address Change
Add Authorized Contact
Remove Authorized Contact
Employee Termination
Employee Name:
Social Security Number:
Date of Termination:
Date of Last Payroll Deduction:
Flex Facts Terminated Employee Claims Policy
Address Change
New Name:
New Phone Number:
New Address:
City:
State:
Zip:
Add Authorized Contact
Name:
Title:
New Contact's Four Digit Pin:
Company:
Phone:
Email:
Remove Authorized Contact
Name:
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