EBPA COBRA and Retiree Document Submission Portal

EBPA COBRA & Retiree Document Submission Portal
Participant's Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Group/Employer's Name
Document Type(s)
File Upload

(Limit of 5 Files)
Cancelof
Please note: The uploaded file must be DOC, DOCX, PDF, GIF, JPG, PNG, TIFF or TIF in format. The uploaded file must be less than 28MB in size.

Please note:Renaming a non-supported file type to a supported file types will not be accepted. EXAMPLE: myfsareceipt.png to myfsareceipt.pdf
Should be Empty:

EBPA COBRA & Retiree Document Submission Portal