State of New York Department of Civil Service
Employee Benefits Division
The W. Averell Harriman 
State Office Building Campus  
Building 1
Albany, NY 12239 


RE:    COBRA Coverage for dependent of {Employee name} 
SS#:  {SS#}

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 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}