COBRA Request for Information If you would like a Combined Services LLC COBRA Administrative Analyst to contact you regarding your available COBRA benefits, please complete and submit the form below. A COBRA Administrative Analyst will contact you within two business days. Contact Information     First Name: Middle Initial: Last Name: Street Address: State: Zip Code: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Home Number: Cell Number: Fax Number: Email Address: Please Contact Me by: Home NumberCell NumberFax NumberE-MailU.S. Mail COBRA Provider Information Employer Name: Health Dental Vision Name of Health Carrier: Name of Dental Carrier: Name of Vision Carrier: Plan: Type: Type: FamilyCoupleParent/ChildIndividual FamilyCoupleParent/ChildIndividual Type:     FamilyCoupleParent/ChildIndividual     Do you have Flexible Benefits (Medical or Dependent Care Reimbursement) through CSLLC? Yes No

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