COBRA Enrollment Form – Loss of Earned Coverage Active Plan

Participants and their qualified dependents who were covered under Plan I should submit this form in order to enroll for COBRA coverage.

COBRA Enrollment Form – Loss of Dependent Status Active Plan

Dependents who lose their dependent status under Plan I due to the death of a participant, divorce from a participant or loss of child status as defined by the Plan, should submit this form in order to enroll for COBRA coverage.