Follow the steps to accurately fill out the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the 'Date' field at the top of the form, indicating the current date of completion.
3. Enter the name of the employee in the designated field provided.
4. Record the date of the last day the employee worked.
5. Note the expiration date of the election period, which is 60 days from the date of notice.
6. Indicate the monthly premium required for the continuation of the Flexible Spending Account (FSA) coverage.
7. Provide the name and address of the employer in the respective fields.
8. Obtain and include the employer's signature to verify the completion of the employer section.
9. In the section to be completed by the employee, enter your name as a former participant in the employer-sponsored FSA.
10. Indicate whether you wish to continue coverage under COBRA by checking the appropriate box.
11. If applicable, state whether you are covered by any other group policy by selecting yes or no.
12. Provide the name of the company if you answered yes to the prior question.
13. Fill in your current home address and phone number.
14. Identify your qualifying event and record the date of occurrence.
15. List all individuals to be continued, including the employee, and provide their names, relations, birthdates, and social security numbers.
16. Sign and date the form to acknowledge your understanding of the rights and responsibilities regarding coverage.
17. After completing the form, review for accuracy before saving changes, downloading, printing, or sharing the form as necessary.

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