COBRA Qualifying Event
Use this form to report a COBRA qualifying event for up to four individuals and have us send the COBRA election form
This form is for groups that have their coverage directly with Delta Dental and utilize our services for only COBRA administration.
Your Full Name:
Your Email Address:
Name of Employer Group: Delta Dental Group Number:
Delta Dental COBRA division. If you have a high and a low option make sure to tell us wihch option here.
The division applies to all four submissions on this form. Please submit a form for each division.