ZapIndex
Generate COBRA Notification
Employer Information
Company Name
Street Address
Address Line 2
City
State Zip
Phone Number
Contact Person
Employee Information
Employee Name
Street Address
Address Line 2
City
State Zip
Date Group Coverage Ends
COBRA Information
Date of Notice
Qualifying Event
Monthly ratesMedicalDentalVision
Employee
Spouse
Child(ren)
Automatically add 2% admin charge to rates
Generate template