EMAIL ADDRESS: dave@cafroagency.com
PHONE: 860-779-DAVE 

COBRA Request Form

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Business Name *

Email *

Your Phone *

Employee Name *

First

Last

Employee's Most Recent Mailing Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Employee's Street Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Termination of Employment Date *

Last Day of Coverage *

Termination Reason *

Full Month Premium for Medical

Full Month Premium for Dental (20+ Employee Groups Only):

Add the 2% Administration Fee (must be the same for all employees):

• yes
• no

Employee Current Coverage

• Employee Only
• Employee + Child
• Employee + 2 or More Children
• Employee + Spouse
• Employee + Spouse and Children

Cancel Medical?

• yes
• no
• not applicable

Cancel Dental?

• yes
• no
• not applicable

Cancel VIsion?

• yes
• no
• not applicable

Cancel LTD?

• yes
• no
• not applicable

Cancel STD?

• yes
• no
• not applicable

Cancel Life?

• yes
• no
• not applicable

Please add any important information not covered on this form:

Dependent Names/Relationships:

Do all dependents live at the above address?

• yes
• no

Employer Signature (Required) *

Submit