Private Plan Appeal and Inquiry Form

For general inquiries, or to appeal a determination, regarding Private Plan, please complete and submit this form. The information you provide will be transmitted securely. Please include as much detail as possible so that our staff can best assist you.

First name

Last name

Social Security Number

Telephone number

Email address

Verify email address

Email Address Anonymous Access

First date of disability (the first day you were unable to work)

Have you received temporary disability benefits from your employer’s insurer? Value is not selected

Employer name

Last day worked

What is your question/issue?

Please upload any relevant documentation from your employer’s insurer, such as benefit or denial letters.

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Private Plan Appeal and Inquiry Form