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Account #:

Amendment Effective Date:

Case Name:

Plan Change Request for an existing Group Policy

Final Proposal# :

Date submitted:

Thank you for the recent communication requesting a change to your current policy. I look forward to this opportunity to provide service to you. To get started, I’ve outlined the change as I understand it, based on recent communications. I need you to confirm and/or fill in any additional details below.

  1. Describe the change being requested.
  • CURRENTPolicy:
  • REQUESTED Policy Change:
  1. Coverage(s) to be changed:

NOTE: If deleting VTL is there replacement coverage? Yes No

3.MEMBERS Impacted: ALL PARTIAL ( list specific job classes or individuals impacted)

4.Indicate name, title and contact information of the person at your company that is authorizing this change:

5.Indicate name, title and contact information of the person(s) we should contact if we have specific questions about this change request:

6.Customer signature: (only needed if changes are not requested electronically by an authorized person at your company)

Name: ______Date:______

INTERNAL USE ONLY: Additional items needed:

  • Refer to Job Aid
  • Proposal NO YES (attach final version)
  • Underwriting approval NO YES (attach approval)
  • Policyholder request (attached)
  • Merger/Acquisition NO YES (attach completed form)

After you’ve completed the details of this change request, send this change request to us. Note: We cannot make any change to your benefit plan until we receive this authorization along with all of the requested information.

There are two simple ways to get this change request to us:

Forward this completed email to me at: {insert email address}

This method is the easiest and fastest way to get your change accomplished. Please forward the completed email from the person in your company that is authorized to make the change.

Print the information and mail it to:

Principal Financial Group

Amendment Team

3025 College Street

Grand Island, NE 68803

To our valued brokers and agents: We understand that some of our customers will want to forward the change request to you first. After you provide your review of the change request, we will be glad to receive this completed email directly from you at the address above. When you forward this completed email, we do ask that the trail of emails contain an approval message from the authorized person at this company.

Thank you for this opportunity to continue servicing your benefit plan.

Please let me know if you have any questions.

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