HEALTH BENEFITS PLAN LANGUAGE REQUEST IFORM
Corporate Compliance must be notified when Health Benefits becomes aware of a new program or vendor,
requiring new plan language or when changes to existing plan language are necessary. To initiate
the request process, this iForm must be completed in full, to include the program or vendor information
noted below. If the appropriate details are not included, the iForm will be returned to you.
Please be aware that Corporate Compliance does not draft language when the client contracts directly
with the vendor for services. In these cases, the client (with the assistance from their legal advisor),
should work directly with that vendor to secure program language for their plan. Corporate Compliance
will review that language, submitted via the iForm, for high level regulatory concerns only.
Date Submitted:
/
/
Name/Contact Number:
/
Email Address:
Region: (Check One)
Central
Northeast
West
1. Did Health Benefits contract with the vendor to provide services for Health Benefits clients?
Yes
No
(If no, see #2)
Vendor Name:
Program Name:
Health Benefits Program Relationship Manager Name:
NOTE: Sample plan language and/or program information is needed in order to draft plan
language for vendors that have a contract with Health Benefits. Please direct these materials to Kris Kiesel
and Lisa Sayerstad via email. DO NOT SUBMIT THIS IFORM UNTIL THIS INFORMATION
IS AVAILABLE.
2. Has a client contracted directly with a vendor for that vendor's services? If yes and you
are submitting plan language from the vendor to be reviewed by Corporate Compliance, please
direct these materials to Kris Kiesel and Lisa Sayerstad via email. DO NOT SUBMIT THIS IFORM
UNTIL THIS INFORMATION IS AVAILABLE.
Yes
No
If yes, Program Name:
3. For NPD template or library language requiring updates, identify the specific section of the NPD
template or library language and direct additional materials to Kris Kiesel and Lisa Sayerstad
via email.
Section/Library Language Name:
Please enter your 3 Character ID:
Form Recipients:
lsayerstad@trustmarkbenefits.com,kkiesel@trustmarkbenefits.com
Additional Recipient (Optional):
[Add this Address]