WorkingAmericanBenefits™

Identify the Company and the Product: (Required)

                          Company                                                              Product     

Select ALLIANZ Life Insurance Company Allstate Financial - AH Life Ins.Co. AmericanCare - Mini Medical Plan American Medical Security Amerius Life Insurance Company Colonial Supplemental Insurance Colorado Bankers Life Insurance Co. CNA Life Insurance Company Fidelity Security Life Insurance Company Fort Dearborn Life Insurance Company FORTIS Life Insurance Company GE Capital Assurance Company Great American Life Insurance Company GUARDIAN Legal Service Guardian Life Insurance Company Humana Insurance Company ING - Relia Star Life Insurance Company Illinois Mutual Life Insurance Company John Hancock Insurance Company Kanawha Insurance Company Physician Mutual Life Insurance Company State Life Insuranc Company Texas Life Insurance Company UnumProvident Life Insurance Co. U.S. Legal Services, Inc. Zurich Kemper - Federal Kemper Life Ins. Co.       Select Group Cancer Insurance Group Critical Illness Insurance Group Dental Plan Group Disability Insurance Group Legal Service Plan Group Life Insurance Group Long Term Care Insurance Group Major Medical Group Mini Medical Plan Individual Cancer Insurance Individual Critical Illness Insurance Individual Dental Plan Individual Disability Insurance Individual Legal Service Plan Individual Life Insurance Individual Long Term Care Insurance Individual Major Medical Individual Mini Medical Plan Other

Identify Yourself: (Required)

First Name:                  MI:            Last Name:     

Street Address:      Apt. or Suite No.:     

City:                                 State:   - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY           Zip Code:  

Social Security No.:    Home Phone.:     Work Phone: 

Complete the following if you are insured in a group product:

Employer/Co. Name:            Payroll Deduction?  Yes  No

Employer/Co. Address: 

Occupation/Duties:     Date Employed: Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  

Hours Wrkd./Week:    Employee No.:     Department/Section No.: 

Describe the Problem in detail: (Required)

Please click on  the SUBMIT button below to submit your complaint for processing.   You will be contacted by a professional insurance agent within the next 48 hours.    Your agent will discuss your complaint with you.   If you are not contacted within the specified period, please contact us at (954)430-8475 or by e-mail at customer_service@workingamericanbenefits.com.