Qualifying Event

Request for Qualifying Event Notice

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* Indicates required field

Are you an active/paid member? *

Your Name *

Company/Organization Name *

Your Email *

Your Phone Number *

Employee's Full Name *

Employee's Date of Birth *

Complete Mailing Address *

Spouse Full Name (if covered) *

Spouse's Date of Birth (if covered) *

Does the spouse have a separate mailing address? *

List any dependent names (if covered) *

Date of the Event *

Last Date of Insurance Coverage *

What event caused the loss of health insurance coverage? *

What is the name of the health plan? *

Enrollment Type for Health Plan *

What is the name of the Dental Plan? (Optional) *

Enrollment Type for Dental Plan *

Your may upload a file if necessary *

Max file size: 20MB

Is there anything we should know? *

Submit Request

Your COBRA Connection
PO Box 1983
Portage, MI 49081

269.220.5710
269.220.5711

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