COBRA QE

Complete the form below to submit your COBRA Qualifying Event.

Customer Service:

Phone: 407-476-5076

Email: dan@bigbenefitsfl.com

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COBRA QE Form

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Success! Continue to Qualifying Plans Below!

COBRA Qualifying Plans

Specify Qualifying Lines of Coverage (check all that apply)

Enter Dependents Below if Applicable

Qualifying Spouse / DP (see next form below for children)

Plans Enrolled On

Continue to Children Below if Applicable

Qualifying Children

Enter Dependents Below if Applicable

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