COBRA Benefits Enrollment Form
Personal Information
Full Name
Social Security Number
Address
City
State
ZIP Code
Phone
Email
Coverage Election
Select Coverage(s)
Medical
Dental
Vision
Other
Plan Type
Single
Employee & Spouse
Employee & Children
Family
Dependent Information
Dependent Name
Date of Birth
SSN
Dependent Name
Date of Birth
SSN
Dependent Name
Date of Birth
SSN
Additional Information
Comments
Signature
Date