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:


Phone Number:


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.


Member #1

COBRA Effective Date:

Day After Group Coverage Term

Please indicate the reason for the COBRA election notice:


First Name:                             Last Name:
          

Date of Birth:                  Gender:
          

Social Security Number:
--

Address:


City:                                                 State:                Zip Code:
                    

Dependent Information
Please enter dependent information if the member has dependent coverages.  Please leave blank of they did not have
dependent 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.


Would you like to add another member?
 
Member #2

COBRA Effective Date:

Day After Group Coverage Term

Please indicate the reason for the COBRA election notice:


First Name:                             Last Name:
          

Date of Birth:                  Gender:
          

Social Security Number:
--

Address:


City:                                                 State:                Zip Code:
                    

Dependent Information
Please enter dependent information if the member has dependent coverages.  Please leave blank of they did not have
dependent 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.


Would you like to add another member?
 
Member #3

COBRA Effective Date:

Day After Group Coverage Term

Please indicate the reason for the COBRA election notice:


First Name:                             Last Name:
          

Date of Birth:                  Gender:
          

Social Security Number:
--

Address:


City:                                                 State:                Zip Code:
                    

Dependent Information
Please enter dependent information if the member has dependent coverages.  Please leave blank of they did not have
dependent 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.


Would you like to add another member?
 
Member #4

COBRA Effective Date:

Day After Group Coverage Term

Please indicate the reason for the COBRA election notice:


First Name:                             Last Name:
          

Date of Birth:                  Gender:
          

Social Security Number:
--

Address:


City:                                                 State:                Zip Code:
                    

Dependent Information
Please enter dependent information if the member has dependent coverages.  Please leave blank of they did not have
dependent 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.
 


Click Submit to send the information to Wolfpack Insurances.
Memo, Please give us any additional information we will need to process this request.