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Cobra
Payment
You must have JavaScript enabled in order to use this page. Please enable JavaScript and then
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this page in order to continue.
Please complete the form below to submit your COBRA Payment. Please note: A convenience fee of 3.5% applies to all online COBRA payments.
To avoid this fee, a check can be mailed to:
FlexFacts.com
PO Box 1226
Brick N.J. 08723
Payment Amount:
$
*
Total Amount Being Charged:
$
Personal Information
First Name:
*
Last Name:
*
Member ID:
*
Last Four Social Security Digits:
*
Address:
*
City:
*
State:
*
Outside US & Canada
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Zip Code:
*
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*
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Phone Number:
*
Cell Phone:
Email Address:
*
Please mail a receipt to the address above
(in addition to the receipt I will receive via email).
Payment Details
Card Type:
*
VISA
MASTERCARD
Card Number:
*
Exp. Month:
*
January
February
March
April
May
June
July
August
September
October
November
December
Exp. Year:
*
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Security Code:
*
This is the 3 digit number printed on the back signature panel.
Additional Comments:
By proceeding with your COBRA payment, you acknowledge and agree that this transaction is final and non-refundable. Once the payment is submitted, it cannot be disputed, reversed, or charged back under any circumstances. Please ensure that you have reviewed all payment details carefully before submitting your payment. If this payment is received after the 30-day grace period for your premium payment, Flex Facts will return the payment.
(Required)
I have read and agree to the terms and conditions.
*
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