COBRA Coverage Request for State Employee's Dependent

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


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:

Need Help Completing the Form?


UB HR Benefits

State Benefit Services

Phone: 716-645-7777


Form Facts

Form Type: MS Word Document

Requirements: Microsoft Word Reader or Application

Updated: 8/2015

Owner: Human Resources, Benefits