Request a change or correction to an individual's name or information.
Your First Name: Your Last Name:
Your Phone Number:
Name of group or individual on billing invoice:
Example: 123456-0 or 91010-150 as shown on your invoice
Please let us know the name of the member who needs an item corrected. Please enter it as it is currently shown on our records.
Information to be Corrected
Member Birth Date
Dependent Birth Date
Other-Use Memo Below
Please let us know the correct Information to use
Would you like a new wallet card sent?
Yes, mail to member address
Yes, mail to group address