EBSA Request for Assistance

Employee Benefits Security Administration

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Request for Assistance from The Department of Labor, EBSA

* Denotes required information. OMB Control Number: 1210-0146 Exp. Date: 09/30/2014

Inquirer Information

First Name:*
Last Name:*
Middle Initial:
Street Address:*
City:*
State/Zip:*
Best phone number to reach you during business hours:* Ext:

Alternate phone number: Ext:
Email Address:
*Note: e-mail address is not required; however if not provided the Department will not be able to contact you by e-mail.

You are a:

Participant/Beneficiary (such as Employee/Dependent)

If you are not the employee, please provide name of the employee
Name:

Plan Sponsor - Employer/Union

Plan Service Provider (such as Third Party Administrator, Accountant, Attorney, etc.)

Health Care Provider

Government Agency

Other (requires comments)

Comments:

Please check all below that apply

The Plan you are contacting us about is a:

Health Plan (such as medical, dental, vision, etc.)

Other Welfare Plan (such as long term/short term disability, severance, life insurance, etc.)

Retirement/Pension (such as 401(k) plan, defined benefit plan, profit sharing plan, etc.)

Employer/Plan Contact Information

Type:

Name:

Best Person to Contact
First Name:

Last Name:

Middle Initial:

Address:

Zip Code:

City:

State:

Phone Number: Ext:

Alternate Phone Number: Ext:

Email:

Website:

Other Information and Comments

Please provide more detailed information about why you are contacting the Department for assistance below. Include information on efforts you have made to contact the plan administrator or employer to resolve the problem. Include a comment on how you believe your issue should be resolved and explain why. Please attach all relevant information to the request for assistance, such as: copies of claims, copies of insurance cards or benefits statements, copies of Notices of Potential Pensions received from Social Security, copies of any responses received from your inquiries to the plan administrator, copies of relevant portions of the plan documents or SPD (summary plan description). If your issue is related to a claim for pension benefits, please include the dates of employment and the employee’s date of birth. If your issue is related to health claims, please include details on the date(s) of service and the
amount(s) of the claim(s). See below on how to attach documents.

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Attachments

If you have attachments you would like to append to your inquiry select the appropriate button below. If you select yes, after submitting your inquiry you will then be directed to the attachment upload page.

Yes, I have attachments I would like to upload.

No, I do not have any attachments.

When you have completed the form click Submit

U.S. Department of Labor | Frances Perkins Building, 200 Constitution Avenue, NW, Washington, DC 20210
www.dol.gov | Telephone: 1.866.4.USA-DOL (1.866.487.2365) | TTY: 1.877.889.5627

Edit Employer/Plan Official

Type:

Name:

First Name:

Last Name:

Middle Initial:

Address:

Zip Code:

City:

State:

Phone Number: Ext:

Alternate Phone Number: Ext:

Email:

Website:

Request for Assistance

General Information: The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for retirement and health benefit plans in private industry. ERISA does not require any employer to establish a plan. It only requires that those who establish plans must meet certain minimum standards. ERISA covers retirement, health and other welfare benefit plans (such as life, disability and apprenticeship plans). Among other things, ERISA provides that those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct. ERISA does not cover plans sponsored by the Federal government, or plans sponsored by a State or local governmental plan (such as a public school, a public college or university or a police or fire department). Additionally, Title I of ERISA generally does not cover church plans.

Requests for Assistance or Complaints involving alleged violations of Title I of ERISA are handled by Benefit Advisors in our national and field offices. Those who file complaints with us can expect a prompt and courteous response from our staff. Every complaint received will be pursued and, if determined to be valid, resolution will be sought through informal dispute resolution. You can expect to receive a status report from the assigned benefits advisor every 30 days. If your valid complaint cannot be resolved informally, it may be referred for further review by our enforcement staff. While we cannot ensure that every complaint will result in an investigation, at the conclusion of enforcement activity, if requested, we will furnish an understandable explanation of the outcome of our review and investigation.

Important Note: Title I of ERISA provides Participants and Beneficiaries with certain rights to request documents and file claims and appeals related to obtaining benefits. Although EBSA can assist you in understanding these rights and in attempting to informally resolve problems, it is important to review your plan documents and follow procedures for making requests and filing claims and appeals timely.

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