COBRA Coverage Transfer Form
Submit this form to request the transfer of your COBRA coverage to a new plan or administrator. Please provide accurate information to ensure timely processing.
Full Name of Covered Individual
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current COBRA Plan or Administrator
*
Current Member ID or Reference Number
*
New Plan or Administrator Name
*
New Plan Contact Email or Phone
*
Requested Transfer Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for COBRA Coverage Transfer
Authorization Signature
*
Submit Transfer Request
Submit Transfer Request
Should be Empty: