CDI Affiliated Services, Inc. COBRA Addition

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Note: This form is completed when there is a "New Hire" to your Employer Benefits Plans.

** Indicates Required Fields.

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Employer Information
Employee Information
Spouse/Dependent(s) Information

Note: When entering spouse and/or dependent(s) information, you MUST under IRS regulations enter their Full SSN and DOB. If this information is not provided, we CANNOT process claims for a spouse and/or dependent(s) under IRS regulations.

Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dependent 6

Date of Signature

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