Employer Services Request Form

Company Name*

Employer / License #*

EmployerXG username is acceptable if unable to provide employer or license #.

Requester Name*

(First Name, Last Name)

Requester Email*

Category*

Select

Description

Please provide a brief description of your request.

File Upload

Please attach any supporting documents that will help us with your request, including benefit sheets, adjustment request forms, screenshots, error messages, etc.

Drag and drop files here or

Send me a copy of my responses