Cobra Help Center Quote Submission

Please fill in all information below to submit an application to an Cobra Help Center agent. This will allow us to began the process of getting you your guaranteed issued health insurance! If you have any questions, or would prefer to talk to an underwriter before proceeding, please call 866-439-0964 ext 10. You may also email us as Admin@CobraHelpCenter.com or even fill out a quick Contact Us form and we will get in touch with you soon!

If your ready to continue, please fill out all fields as thoroughly and as accurately as possible.

First Name

Last Name

Date of Birth

E-mail Address

Username

Please create a username to access your information.

Enter password

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Confirm Password

Home Address

Home Address 2

City

State

Zip Code

Primary Phone

Please leave a phone number where you can be reached. Type numbers with NO dashes, parenthesis, or periods.

Format: 5555555555

Cell Phone

Please leave a phone number where you can be reached. Type numbers with NO dashes, parenthesis, or periods.

Format: 5555555555

Fax

Cobra Start Date

Cobra Insurance Carrier

This is the company that is providing the COBRA to you. This is not your former employer.

Reason on COBRA

Please Explain

Select all Pre-Existing Conditions

Arteriosclerosis Artificial Heart Valve Cardiomyopathy Chemical Dependency Cirrhosis of the Liver Coronary Disease Cystic Fibrosis Dermatomyositis Huntington's Disease Hydrocephalus Juvenile Diabetes Kidney Failure Leukemia Lupus Cancer Multiple Sclerosis Muscular Atrophy or Dystrophy Myasthenia Gravis Open Heart Surgery Paraplegia or Quadriplegia Parkinson's Disease Polyarteritis Sclerosis Psychotic Disorders Anemia Stroke Topectomy and Lobotomy Wilson's Disease

Please select any condition you or any dependent has been treated for within the last 10 years.

Additional Information

Cobra Help Center Leader in Guaranteed Major Medical after COBRA

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