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
a form.

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:
  Client ID will be on the letter we sent you

Address:


City:                                                         State:                Zip Code: 
                    
 

Phone Number:            
 
 
E-mail Address:


E-mail Invoicing Option:

     

Information on the person electing COBRA continuation
If only a dependent is extending the coverage, please put their information here.
SSN:

First Name:                            Last Name:                                      Gender:                           Date of Birth:
                              

 



In addition, COBRA coverage needs to be extended on the following dependents:
Please leave these fields blank if you do not have dependents or children continuing the coverage.

 
  First Name Last Name (if different) Gender Date of Birth
Spouse/Domestic Partner
Child #1
Child #2
Child #3
Child #4
Child #5
 
Please give us any additional information that you feel is necessary to process this request.


By clicking the "Submit Form" button below I acknowledge that I have read and understand my COBRA rights and wish to
elect the coverage.

I HEREBY REQUEST ENROLLMENT IN THE HEALTH BENEFITS CONTINUATION PLAN FOR MYSELF AND ELIGIBLE
QUALIFIED DEPENDENTS LISTED ON THIS FORM AND AGREE TO PAY THE PREMIUM AS REQUIRED. I UNDERSTAND
THAT CONTINUATION COVERAGE WILL TERMINATE UNDER SEVERAL CIRCUMSTANCES, INCLUDING: THE DATE I
OR A CONTINUED DEPENDENT BECOME COVERED UNDER ANOTHER GROUP PLAN, OR ON THE DATE ON WHICH
THE GROUP PLAN ENDS.  I ALSO UNDERSTAND THAT IF I WAS DISABLED WITHIN 60 DAYS OF THE COBRA
QUALIFYING EVENT, I MAY BE ELIGIBLE FOR EXTENDED CONTINUATION COVERAGE.

Once you click on SUBMIT FORM you will also be directed to a confirmation page.  From the confirmation page you can make
a premium payment via credit card or have the premium drafted from your checking or savings account.  If you have us draft the premium from your checking or savings account you will be given the option of having us set up the automatic deduction from the account.