Dependent Coverage Continuation Application
Apply to continue coverage for your eligible dependent. Please complete all required fields to ensure timely processing.
Applicant's Full Name
*
First Name
Last Name
Applicant's Email Address
*
example@example.com
Applicant's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Dependent's Full Name
*
First Name
Last Name
Dependent's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Dependent
*
Please Select
Spouse
Child
Other
Select Coverage Type to Continue
*
Medical
Dental
Vision
All Available
Reason for Continuation Request
*
Please Select
Loss of coverage
Divorce/Legal Separation
Dependent aged out
Other
Submit Application
Should be Empty: