Follow the Executive Response Guidelines for escalation resolution prior to submitting this form. Executive Response - Tier II Agent Agent InformationThis field is hidden when viewing the formRecord Type ID01239000000UR9EAAWYour Name*Select your nameAna MarquezDan Mark GambanDonovan BayliffGabrielle LeflerJayson JadulcoJennifer CirinnaJennilyn MalakiJessica KitchJohn Ian Carlo MirandaJonathan LontocoKristi ColemanLhea Lhyn YgrubayMa. Ada LastimosaMhika De LimaMichael Angelo QuitoMonaliza MappalaNONE INVOLVEDNorman Carlo ToledoNorman ToledoRudolph VersozaShantel GrosecloseTiffanie ManleyMichael TrejoJoseph DelgadoAnna HerreraIberty AndujarDeb HedgerTrisha Mae RoqueJeric BaylonClient Name*Enter the client name - this is the financial institution and not the customer's name.Reason for Escalation*Select escalation reasonBilling including hard decline, soft declines, & prepayCancellation including restart requestsClaimsfmservice.comForms including requests or returningRefunds including denying enrollmentThreatening lawyer / legal actionUnable to locate in the systemOther CLAIMS: Please DO NOT use this form for any reasons related to a CLAIM - please submit a Claims Workflow. CANCEL CONFIRMATIONS: You still need to have the cancellation form submitted to avoid delays. REACTIVATION: Please follow the Reactivation Procedure. UNABLE TO LOCATE IN THE SYSTEM: DO NOT use this for billing rejects. This should be used if the policy cannot be found in Artemis. Go to the Claims WorkflowFMService Instructions Please be sure to include details within the Escalation Notes Below to help us work, research, and resolve the customer's challenge: Explain the nature of the challenge as well as the exact wording for any error messages or error codes a customer is receiving on the screen. It is important to capture the exact wording. Please include the date & time the customer experienced the challenge. Please be as specific as is possible. Page on site where issue occurred. Depending on the time of the month, customers should still be instructed to mail in a payment to avoid a lapse in coverage (if payment attempt is the reason for the call) while the issue with fmservice is being researched. For customers NOT receiving emails from fmservice, please be sure to instruct them to verify their spam or junk settings as well as to look in their "Social" and "Promotion" folders for customers using Gmail. Please DO NOT use this for billing rejects - select the billing reason in those instances. This should be used if the policy cannot be found in Artemis.Policy Reactivation (Restart) Instructions Customers who have had their policy cancel due to nonpayment (usually associated with a no longer valid billing account) are able to have their coverage reactivated by following these steps: Send the account number change form for HAP and Recuperative Care – ACCT#CHG / ACT#CHG If the financial institution is a credit union, the account number provided must be from the financial institution as indicated on the customer coverage screen Send the activate letter form for Accidental Death & Dismemberment - ACTIVATE REMEMBER: Do not send the ACTIVATE letter to Transamerica customers. fmservice.com Customers who have at least one active account can go to fmservice.com and see their cancelled coverages. Customers can reactivate a cancelled coverage on fmservice.com.Escalation Notes*Please be concise and specific.Customer / Caller InformationCaller's name* First Last Caller's phone number*Caller's email address* Email address is used for follow-up in the event we are unable to make contact via phone. It is not used for marketing.Name of primary insured (not the caller's name if third party)* First Last Coverage ID of primary insured*Product*Select insurance productAccidental DeathAccident ExpenseAD&DHAPOtherRECUP CARETERM LIFECritical IllnessCarrier*Select carrierMinnesota Life / SecurianChubb / Federal Insurance CompanySiriusTransamericaHartfordZurichOtherState*This field is hidden when viewing the formStatusRequested - ExRT
