COBRA Election Form
Use this form to securely make your COBRA election only if you have received a COBRA election form from Wolfpack
Insurance Services. If you did not receive a COBRA election form from us, please check with your former employer for
COBRA coverage is always effective on the day after you group coverage terminates. You have 60 days to notify us you
wish to continue the coverage.
Please complete the information below for the person continuing the coverage under COBRA.
Client ID will be on the letter we sent you
City: State: Zip Code:
Information on the person electing COBRA continuation
If only a dependent is extending the coverage, please put their information here.
First Name: Last Name: Gender: Date of Birth: