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GGFM-ER-8514 Maxwell Health Employer Information Form 02/24 <br />Benefits administrators and plan administration <br />Please let us know who you would like to have access to the Sun Life online employer web portals. <br />The head administrator automatically has access to all locations (if multiple) and all areas of the site: <br />•Billing—for online billing customers only <br />•Claims—available to customers with Sun Life Disability Products <br />•Evidence of Insurability <br />•Policy documents (contracts, booklets, general forms, and benefits administration guides) <br />Primary benefits administrator <br />Name of primary benefits administrator <br /> <br />Title <br /> <br />Street address <br /> <br />City <br /> <br />State <br /> <br />Zip code <br /> <br />Phone number <br /> <br />Fax number E-mail address <br /> <br /> Head web administrator <br />(Access to ALL capabilities) <br />Will this individual be administering the Maxwell technology? ........................................................................... Yes No <br />Name of primary Maxwell administrator E-mail address <br />Will this individual be responsible for reconciling discrepancies from EDI connections? .................................. Yes No <br />Name of EDI discrepancy contact E-mail address <br />Please add any additional Sun Life web administrators below along with the type of access required. After registering <br />online, head administrators may also add additional users to the employer web portal. Please see the Manage Users <br />section of the site for more information. <br />Additional Web Administrators <br />Name of benefits administrator Title <br />Street address City State Zip code <br />Phone number E-mail address Type of access <br />Billing EOI Claims Documents <br />Name of benefits administrator Title <br />Street address City State Zip code <br />Phone number E-mail address Type of access <br />Billing EOI Claims Documents <br />Name of benefits administrator Title <br />Street address City State Zip code <br />Phone number E-mail address Type of access <br />Billing EOI Claims Documents <br />Docusign Envelope ID: BA987120-63B9-40BD-A4CA-C6E248AD9B65 <br />2930 Wetmore Ave. Suite 5A <br />X <br />HR Operations Manager <br />X <br />cbardwell@everettwa.gov <br />Chelsi Bardwell <br />WAEverett <br />X <br />425-257-8708 <br />98201