COBRA Coverage Request for State Employee's Dependent

State employee requests COBRA coverage for a dependent who has lost health insurance coverage.  

Instructions

Write to New York State Department of Civil Service:

  1. Download the Microsoft Word document
  2. Add your information in place of {  }'s
  3. Print the document (and a copy for yourself)
  4. Sign the document
  5. Send the completed document to the address in the letterhead

Download the Request Template

Or Call

New York State Department of Civil Service Employee Benefits Division at these numbers:
 
518-457-5754
1-800-833-4344

Need help completing the form?

Send email, phone or submit a question

Amy Myszka

Director

Benefits and Work Life Balance

Phone: 716-645-5357

Email: amyszka@buffalo.edu

About the Issue or Your Comments

 
 
(We'd like to respond to you.)
(Required)

Form Facts

Form Type: MS Word Document

Requirements: Microsoft Word Reader or Application

Updated: 8/2015

Owner: Human Resources, Benefits