Tehama County
If this is an emergency or life-threatening situation, please call 911.
For immediate benefit assistance, please call ACI at 800.932.0034.
Covered Employee Information
Corporation:
Location:
Select...
Default Location
Covered Employee Name:
Length of Service:
Select...
< 6 Months
< 1 Year
1 - 5 Years
6 - 10 Years
11 - 15 Years
16 - 20 Years
20+ Years
Your Information:
Your Name:
Age:
Gender:
Select...
Male
Female
Email Address:
Confirm Email Address:
Phone:
Zip Code:
Your Relationship to Employee:
Select...
Family Member
Other
Self
Have you used this program before?
Select...
Yes
No
Please Tell Us About Your Needs
Request Category:
Select...
Child Care
Community-Based Resources
Education
Elder Care
Emotional Wellness
Financial
Housing
Legal
Pet Care
Self Care
Transportation
Travel
Please Provide a Brief Description of your Request:
Referral Source:
Select...
Email
Onsite Event
Other Employee
Family Member
Human Resources
Orientation / Training
Poster / Brochure
Health Fair
Intranet
Website
Used Before