Qualifying Event Information (C.O.B.R.A.)

Please fill in your information in the boxes provided so that it can be transmitted to the provider.

When completed, select "Submit".

Employer:
Employee SSN:
Employee Name:
Address
City:		State:		Zip:
Daytime Phone:
Evening Phone:
Email:
Birth Date:
Hire Date:
Qualifying Event:
Event Date:
Waiting Period:
Loss of Coverage:

Dependents:

Name		Birth Date		SSN		Relation

	Entire Plan		Medical		Dental		Vision
Sgl $
____ $
Fam $
Due $

Additional Address or Instructions: