Insurance Makes Me Sick!!!!!!!!!!!!!!!wpe2.jpg (12500 bytes)

COBRA Notification Letter

To print your COBRA Letter, simply complete the fields below, click on the submit button and print it on your printer.
All fields are required for this form to print correctly
Company Name:
Plan Administrator:
Address:
City, State and Zip Code:
Phone:
E-Mail Address:
.
Employee Name:  
First Name Last Name
Employee Age: *Required for us to send a short term medical quote.
Employee Address:
City,State and Zip Code:
Date of Termination: //
Insurance Company Name:
Employee Only Rate: (you can add a 2% administrative fee to this rate if you wish)
Employee Spouse Rate: (you can add a 2% administrative fee to this rate if you wish)
Employee Child Rate: (you can add a 2% administrative fee to this rate if you wish)
Employee Children Rate: (you can add a 2% administrative fee to this rate if you wish)
Family Rate: (you can add a 2% administrative fee to this rate if you wish)

InsuranceMakesMeSick.com can send this employee a Short Term Major Medical Application to cover this employee until he / she finds individual coverage or satisfies the waiting period with their new employer. If the employee elects the short term policy, it will eliminate the need for the employee to pay you the premiums each month, thus eliminating some exposure on your part.
Please send a Short Term Major Medical application to this employee.