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As of June 23rd, 2021 COBRA members will need to register for the new member portal. Please select Register New User to continue. If you have already recently registered with the new portal please login using the COBRA login option below

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Enrollment Options

  • Request Online Enrollment Information
  • Request Information on Enrollment File Templates
Flex FMLA Information
  • FMLA Guidance
  • FMLA Request Form
  • FMLA Return Form
  • FMLA Retroactive Worksheet
Flex Enrollment / Change Forms
  • Flex Enrollment / Change Form
  • Flex Enrollment / Change Form with Employer Contribution
  • Flex Enrollment / Change Form Limited FSA
  • Flex Enrollment / Change Form Limited FSA with Employer Contribution
  • Enrollment Form (Español)
  • Notice of Member Termination
Transportation Enrollment Forms
  • Transportation Benefits Enrollment / Change Form
  • Transportation Benefits Enrollment / Change Form with Employer Contributions
HRA Enrollment Forms
  • HRA Enrollment / Change Form
  • HRA Enrollment / Change Form with Dependents
Additional Forms
  • Joint Processing Enrollment Form
  • Premium Only Enrollment Form
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Corporate Headquarters 2806 S. Garfield St.
P.O. Box 3018
Missoula, MT 59806-3018
Toll Free: 800-877-1122
Local: 406-721-2222
inquire@askallegiance.com
Companies Allegiance Benefit Plan Management, Inc. Allegiance Advantage Allegiance COBRA Services, Inc. Allegiance Life & Health Insurance Company, Inc. Allegiance Care Management
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Allegiance Benefit Plan Management, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Language Access Services: The information above is a requirement of Section 1557 of the Affordable Care Act effective August 18, 2016. It is required to assist those who may need assistance with the English language or translation assistance to a different language in which they are more fluent.

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