Pay COBRA

COBRA Health Insurance Payments

There are credit card surcharges associated with making your COBRA Premium Payment Online. They have been pre-calculated and included for your convenience.

COBRA Payments will be applied to the month(s) due and owing and a receipt from the Roofers Local 195 Fund Office will be mailed to you.

If you wish to continue, use the form below to select the Cobra Premium Option and select the appropriate plan for which you are paying.

We accept all major credit/debit cards and PayPal for processing.

You can also call or stop by the Fund Office to make COBRA Premium payments via Credit or Debit card.

Member Name(Required)

First Last

Phone(Required)

Email(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Payment Options

Payment Amount(Required)

Please remember to round up to the next full dollar amount. Processing Fees are added separately on this form - do NOT add them here.

Plan A - Employee Only - $1,251.63

Plan A - Employee & Spouse - $2,038.23

Plan A - Family - $2,264.90

Plan B - Employee Only - $1,002.20

Plan B - Employee & Spouse - $1,793.97

Plan B - Family - $2,092.05

Total

Payment Method(Required)

American Express

Discover

MasterCard

Visa

Maestro

Card Number Expiration Date Security Code Cardholder Name

ROOFERS LOCAL UNION #195

ROOFERS LOCAL UNION #195

COBRA Health Insurance Payments

Payment Options

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