COBRA Coverage Request for State Employee's Dependent

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
   

Form Type: MS Word Document

Requirements: Microsoft Word Reader or Application

Updated: 8/2015

Owner: Human Resources, Benefits