*****ECHO UI (Universal Interface) Access Request******
This form should be sent by an Authorized user only (supervisor or higher). Please fill in all areas for the user you are requesting access. Please complete a separate form for each user.
Select ONE:
This is a request to
ADD,
DEACTIVATE,
MODIFY
User ID:
User Name:
User Full Email Address:
User Work Day Department (Example: 1160 HB Corporate Customer Service):
Requesting Manager:
Title:
Date Requested:
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Effective Date:
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**EFFECTIVE DATE is the day the user will be able to activate their account. Activation link expires 48 hours after being sent**
Function Role Required: (please check all that apply}
Health Benefits (00031)
HCSC (00305)
Nippon Life Benefits (00057)
Flex/HRA/HSA (00123)
Check if access should include:
Employee Plans (Trustmark, Health Benefits, HFIT)
Please enter any comments:
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Every effort is made to complete your request in a timely manner. There are circumstances when it cannot be completed immediately. Users will be set up based on Effective Date.
We require 2 business days to review and complete this request. Requests received after 3:30pm cst Mon-Thurs or 10:30am cst Fri will be deferred to the next business day.
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Please enter your 3 Character ID:
Form Recipients:
hkwak@trustmarkbenefits.com
Additional Recipient (Optional):
[Add this Address]