Changes In My Benefits Coverage


My spouse, dependent(s) and/or I are no longer eligible for other coverage.


My spouse, dependent(s) and/or I have become eligible for other coverage.


My spouse, dependent(s) and/or I have had changes in Medicare, CHIP, Medicaid or NC Health Choice eligibility or enrollment.


I am on unpaid Family Medical Leave.


Whatever your life change, you’ll likely need this form to report a change in your benefits status. Once it’s completed, return it with supporting documentation to:

By Email: MissionBenefits@sba-inc.com
Questions? Contact HR Direct Connect by phone at (828) 213-5600

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