Initial Notification

Request for Initial Notification

For newly covered employee, newly added spouse, employee recalled from lay-off, or back to full time after being part time. Complete the information below ONLY if the employee and/or spouse enroll in any of your medical plan coverages. Do NOT send if they declined coverage.

* Indicates required field

Are you an active/paid member? *

Your Name *

Company/Organization Name *

Your Email *

Your Phone Number *

Employee's Full Name *

Spouse Full Name (if covered) *

Complete Mailing Address *

Does the spouse have a separate mailing address? *

Is there anything we should know? *

Your may upload a file if necessary *

Max file size: 20MB

Date Submitted *

Submit Request

Return to Priority Support

Do NOT forget to contact Your COBRA Connection if a spouse is added to the employee coverage upon initial enrollment, marriage, open enrollment, or as a result of a HIPAA special enrollment situation.

Call us immediately if a dependent child is being added to the plan as a result of a qualified medical child support order.

Phone, Email or Text Anytime

Your COBRA Connection
PO Box 1983
Portage, MI 49081

269.220.5710
269.220.5711

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