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Web Group Number Update Form
Please complete the form below and click 'Submit'.
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Instructions: Use this form to Add or Remove Group Numbers from an existing Web user account. We will send you an email when this change has been processed.
Name of Broker: (required)
Name of Employer: (required)
Employer Tax ID (EIN): (optional)
Group Email Address for Notifications: (required)
(Please provide one email address at your company to receive notifications of member policy updates or address changes.)
New Group Numbers You'd Like us to Add: (optional)
(Please include complete group/subgroup numbers without any spaces or dashes using commas to separate numbers. Ex. 123456,123456,...)
Old Group Numbers You'd Like us to Remove: (optional)
(Please include complete group/subgroup numbers without any spaces or dashes using commas to separate numbers. Ex. 123456,123456,...)
Your Current Web Group Administrator Username: (required)
Your Name: (required)
First   Last 
Your Telephone Number: (required)
(area)    
Your Email Address: (required)
Additional Information:
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