TICUA Benefit Consortium Suggestion & Feedback Form

All submissions will be acknowledged within three (3) business days.

Please Tell Us About Yourself

First Name

Last Name

Address

Apt #/PO Box

City

State

Zip Code

Home Phone

Work Phone

Fax

Email address

Institution of Employment or Affiliation

I am a(n):

Please choose one

Please provide details regarding your question or concern

Have you contacted anyone?

Yes

If so, whom?

Approximately when?

What action was taken?

Do you feel the action taken was sufficient?

Yes

If not, why?

Thank you for completing this form. Please contact us with any questions at 615.292.3535 or tbc@ticua.org