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653. 8381 Toll-Free 855. 890. 7239 Fax 855. 890. 7238 Email customerservice NueSynergy. com 2-2016 C. I agree to all the changes indicated above. / Employer Authorized Signature Required Mail fax or scan completed form to NueSynergy Administration Services 4601 College Blvd Suite 280 Leawood KS 66211 Employer Keep a copy for your records and provide a copy to the employee. Name Change From To Change in Marital Status Change in legal marital status including marriage death of the spouse...
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