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COBRA Enrollment
Personal Information
Employee / Qualified Beneficiary Name
*
Social Security Number:
*
Date of Birth
*
Gender
*
A
Male
B
Female
Primary Applicant Phone Number
*
Primary Applicant Email Address
*
Primary Applicant Address
*
Date of Qualifying Event
*
Benefit Enrollment:
MEDICAL Elections (Monthly Cost to Employee/Eligible Beneficiary)
*
A
I am waiving MEDICAL COBRA coverage.
B
Employee Only - $1,298.74
C
Employee + Spouse - $2,961.03
D
Employee + Children - $2,518.93
E
Employee + Family - $4,262.19
DENTAL Elections (Monthly Cost to Employee/Eligible Beneficiary)
*
A
I am waiving DENTAL COBRA coverage.
B
Employee Only - $33.46
C
Employee + Spouse - $73.68
D
Employee + Children - $74.21
E
Employee + Family - $117.36
VISION Elections (Monthly Cost to Employee/Eligible Beneficiary)
*
A
I am waiving all VISION COBRA coverage.
B
Employee Only - $8.65
C
Employee + Spouse - $17.34
D
Employee + Children - $14.68
E
Employee + Family - $24.20
Do you wish to enroll any additional eligible dependents?
*
A
Yes
B
No
Qualified Beneficiaries/Dependent Info: Your Spouse/Children
Name (1)
*
Relationship (1)
*
Gender (1)
*
A
Male
B
Female
Date of Birth (1)
*
Social Security Number (1)
*
Dependent #2
Name (2)
*
Relationship (2)
*
Gender (2)
*
A
Male
B
Female
Social Security Number (2)
*
Date of Birth (2)
*
Dependent #3
Name (3)
*
Relationship (3)
*
Gender (3)
*
A
Male
B
Female
Social Security Number (3)
*
Date of Birth (3)
*
Dependent #4
Name (4)
*
Relationship (4)
*
Gender (4)
*
A
Male
B
Female
Social Security Number (4)
*
Date of Birth (4)
*
Agreement
Signature
*
Signature
Submit