COBRA Benefits Enrollment Form
Participant Information
Full Name
Address
City
State
ZIP Code
Phone Number
Email Address
Social Security Number
Date of Birth
Qualifying Event Information
Type of Qualifying Event
Termination of Employment
Reduction in Hours
Divorce or Legal Separation
Death of Covered Employee
Other
Date of Event
Coverage Election
Medical
Dental
Vision
Other
Dependent Information
Dependent Name
Date of Birth
Relationship
Dependent Name
Date of Birth
Relationship
Signature
Signature
Date