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COBRA Member Information (existing COBRA members only)

This form should be completed for any existing COBRA members that need to be transitioned over to COBRA Administration & Health Services, Inc. Fields marked with an asterisk (*) are required.

Please do not use this form for anyone requiring a COBRA notice but instead use the Qualifying Event Form.

EMPLOYEE INFORMATION

Name of Employer:*
Participant Name:*
Address 1:*
Address 2:
City:*
State:*
     Zip:*
Home Phone:
Date of Birth: * (MM/DD/YYYY)
Social Security: *
- -

TYPE OF COVERAGE

Check all that apply. If you offer more than one medical or dental plan please list the plan next to the coverage.

HEALTH COVERAGE

Health Plan Provider:

Health Plan Premium:

Health Plan Type:
Individual Plan
Employee/Spouse
Employee/Children
Family

DENTAL COVERAGE

Dental Plan Provider:

Dental Plan Premium:

Dental Plan Type:
Individual Plan
Employee/Spouse
Employee/Children
Family

FIRST OTHER COVERAGE

Other Plan Provider:

Other Plan Premium:

Other Plan Type:
Individual Plan
Employee/Spouse
Employee/Children
Family

SECOND OTHER COVERAGE

Other Plan Provider:

Other Plan Premium:

Other Plan Type:
Individual Plan
Employee/Spouse
Employee/Children
Family

THIRD OTHER COVERAGE

Other Plan Provider:

Other Plan Premium:

Other Plan Type:
Individual Plan
Employee/Spouse
Employee/Children
Family

DEPENDENTS

SPOUSE

First Name:
Last Name:
Date of Birth:
SSN:

DEPENDENT #1

First Name:
Last Name:
Date of Birth:
SSN:

DEPENDENT #2

First Name:
Last Name:
Date of Birth:
SSN:

DEPENDENT #3

First Name:
Last Name:
Date of Birth:
SSN:

COVERAGE DATES

Date COBRA began:* (MM/DD/YYYY)
Date COBRA paid through:* (MM/DD/YYYY)

What event activated eligibility?

Voluntary Termination of Employment
Involuntary Termination of Employment
Reduction in Hours
Retirement
Entitlement to Medicare (Part A and/or B)
Divorce or Legal Separation
Loss of Eligibility Status of a Dependent Child
Death of Employee
Termination Due to Total Disability