860-779-DAVE dave@cafroagency.com

COBRA Request Form

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

COBRA Request Form

Please enable JavaScript in your browser to complete this form.
Employee Name
Employee's Most Recent Mailing Address
Employee's Street Address
Add the 2% Administration Fee (must be the same for all employees):
Employee Current Coverage
Cancel Medical?
Cancel Dental?
Cancel VIsion?
Cancel LTD?
Cancel STD?
Cancel Life?
Do all dependents live at the above address?

** PLEASE HIT THE SUBMIT BUTTON ONCE ONLY **

 

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The CAFRO agency is a division of Patriot Growth Services, LLC.
Securities offered through Westminster Financial Securities, Inc. Member FINRA/SIPC. Check the background of this firm or investment professional on FINRA’s BrokerCheck.