COBRA Enrollment Form – Loss of Earned Coverage Active Plan

Participants and their qualified dependents who were covered under Active Plan  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 Active Plan 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.