Employee Name
*
Prefix
First
*
Last
*
Suffix
Enrollee/Employee ID or SSN
*
Group Name or Number
*
Please update:
*
Address
Phone Number
Email
Name
ADDRESS UPDATE
New Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
PHONE NUMBER UPDATE
New Phone Number
###
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###
-
####
Phone Type
Home
Cell
Work
PHONE NUMBER UPDATE
New Phone Number
###
-
###
-
####
Phone Type
Home
Cell
Work
EMAIL UPDATE
Name
Prefix
First
Last
Suffix
Email Address
For newsletter purposes only. This information will not be sold or used by LifeWell for any other means.
Newsletters?
YES
NO
Would you like to receive our email newsletter with the latest LifeWell information and tips?
EMAIL UPDATE
Name
Prefix
First
Last
Suffix
Email Address
For newsletter purposes only. This information will not be sold or used by LifeWell for any other means.
Newsletters?
YES
NO
Would you like to receive our email newsletter with the latest LifeWell information and tips?
NAME UPDATE
Old Name
Prefix
First
Last
Suffix
New Name
Prefix
First
Last
Suffix
Reason for Change
Misspelling
Marriage
Adoption
Divorce
ID Card Needed
YES
NO
NAME UPDATE
Old Name
Prefix
First
Last
Suffix
New Name
Prefix
First
Last
Suffix
Reason for Change
Misspelling
Marriage
Adoption
Divorce
ID Card Needed
YES
NO
Other Information
Upload a File
Please upload any necessary supporting documentation - such as a marriage certificate, birth certificate, or divorce decree here.
**NOTE: After you click Update Info you will be directed to our Thank You page. If you are not redirected please scroll up and make sure you have completed all required fields.
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