Set up Premium Invoicing for a COBRA Member
The following member have electing COBRA and need to be invoiced.

Your full Name:


Your E-mail Address:


Phone Number:


Name of Group or Client:                         Dental Dental Group Number:
          


COBRA Member #1 Information

COBRA Effective Date:           SSN:                                                  Gender:
          --          

COBRA Reason:


First Name:                            Last Name:                                      Date of Birth:
                    


Address:


City:                                                State:                Zip Code:
                    

Dependent Infomation
Please leave fields blank if you do not have dependents or children to enroll.

  First Name     Last Name (if Different) Gender   Date of Birth
Spouse/Domestic Partner
Child #1
Child #2
Child #3
Child #4
Child #5

If your group has several plan options, please use the text box below to indicate which plans apply to this member. All Dependents
will be added to the same plans as the employee unless noted.


Would you like to add another member?
 

COBRA Member #2 Information

COBRA Effective Date:           SSN:                                                  Gender:
          --          

COBRA Reason:


First Name:                            Last Name:                                      Date of Birth:
                    


Address:


City:                                                State:                Zip Code:
                    

Dependent Infomation
Please leave fields blank if you do not have dependents or children to enroll.

  First Name     Last Name (if Different) Gender   Date of Birth
Spouse/Domestic Partner
Child #1
Child #2
Child #3
Child #4
Child #5

If your group has several plan options, please use the text box below to indicate which plans apply to this member. All Dependents
will be added to the same plans as the employee unless noted.


Would you like to add another member?
 

COBRA Member #3 Information

COBRA Effective Date:           SSN:                                                  Gender:
          --          

COBRA Reason:


First Name:                            Last Name:                                     Date of Birth:
                    


Address:


City:                                                State:                Zip Code:
                    

Dependent Infomation
Please leave fields blank if you do not have dependents or children to enroll.

  First Name     Last Name (if Different) Gender   Date of Birth
Spouse/Domestic Partner
Child #1
Child #2
Child #3
Child #4
Child #5

If your group has several plan options, please use the text box below to indicate which plans apply to this member. All Dependents
will be added to the same plans as the employee unless noted.


Would you like to add another member?
 

COBRA Member #4 Information

COBRA Effective Date:           SSN:                                                  Gender:
          --          

COBRA Reason:


First Name:                            Last Name:                                  Date of Birth:
                    


Address:


City:                                                State:                Zip Code:
                    

Dependent Infomation
Please leave fields blank if you do not have dependents or children to enroll.

  First Name     Last Name (if Different) Gender   Date of Birth
Spouse/Domestic Partner
Child #1
Child #2
Child #3
Child #4
Child #5

If your group has several plan options, please use the text box below to indicate which plans apply to this member. All Dependents
will be added to the same plans as the employee unless noted.
 


Please provide any further information you feel is necessary to process your request in the memo below.