Cobra Payment

Please complete the form below to submit your COBRA Payment. Please note: A convenience fee of 3.5% applies to all online COBRA payments.

To avoid this fee, a check can be mailed to:
FlexFacts.com
PO Box 1226
Brick N.J. 08723

Payment Amount:

$ *

Total Amount Being Charged:

Personal Information

First Name: *

Last Name: *

Member ID: *

Last Four Social Security Digits: *

Address: *

City: *

State: *

Zip Code: *

Country: *

Phone Number: *

Cell Phone:

Email Address: *

Please mail a receipt to the address above (in addition to the receipt I will receive via email).

Payment Details

Card Type: *

Card Number: *

Exp. Month: *

Exp. Year: *

Security Code: *

This is the 3 digit number printed on the back signature panel.

Additional Comments:

By proceeding with your COBRA payment, you acknowledge and agree that this transaction is final and non-refundable. Once the payment is submitted, it cannot be disputed, reversed, or charged back under any circumstances. Please ensure that you have reviewed all payment details carefully before submitting your payment. If this payment is received after the 30-day grace period for your premium payment, Flex Facts will return the payment.

(Required) I have read and agree to the terms and conditions. *