participant login
employer login
Cobra login
broker login
Cobra Payment
MENU
Home
About
About Us
Careers
Services
Resources
News
Guides
FAQ
Tutorial Videos
Mobile App
Eligibility List
Forms
Contact Us
Shop for Eligible Products
participant login
employer login
Cobra login
broker login
Cobra Payment
low cost flex administration done right
Employee Request
Form
Personal Information:
Company Name:
Employee Name:
Telephone:
Email:
Social Security Number:
Type of Service:
Name Change
Address Change
Email Change
Email Address Change
New Email Address:
Phone Number Change
Phone Number Change
New Phone Number:
Election Change
Please have your HR department contact us regarding this change.
Terminate a Dependent
Terminate a Dependent
Name on the card that is being terminated:
Dependent Date of Birth:
Relationship to Employee:
Date of Dependent Termination:
Add Dependent
Request Card for Dependent
Request New Card
New Name:
Dependent First Name:
Dependent Last Name:
Dependent SSN:
dependent date of birth:
Relationship to Employee:
-- Select One --
Employee's address on file
Alternate shipping address
dependent card should be mailed to:
Address:
City:
State:
Zip:
Address Change
Current Address:
City:
State:
Zip:
Check here if submitting a Change of Address
© 2023 Flex Facts
Privacy Policy
Website by
Duvys Media
