COBRA forms

Visit these quick links to find the right COBRA form

Got COBRA questions? Find the COBRA forms you need to manage your COBRA coverage.

Click the form name to access the COBRA form and learn how to complete it.

• COBRA Addition of a Dependent form
• Recurring Automatic Payment (ACH) Request form
• COBRA Benefits Termination form
• COBRA Contact Information Change form
• COBRA Medicare Extension Request form
• COBRA Second Qualifying Event form
• COBRA Social Security Disability Extension (SSDE) form

Here’s how to reset the password for your COBRA online account.