COBRA TER PER REQ (BC/JH) [ltr]
August 9, 2013
State of New York
Department of Civil Service
Employee Benefits Division
Empire State Plaza
Albany, NY 12239
RE: COBRA Coverage for dependent of {Employee name}
Employee’s SS#: Social Security Number
Dear COBRA Unit:
I am writing to request a COBRA application for my dependent who recently lost health insurance coverage due to a change in status. My name is {Name}, my social security number is {SS#}, and my dependent {Name} has lost coverage as of {last day covered}.
Please send the COBRA application to my home address listed below:
{Address}
{Address 2}
{City, State, Zip}
Thank you for your attention to this matter. If you have any questions, please feel free to give me a call at {telephone number}.
Sincerely,
{Name}
................
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