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                Get Cobra Enrollment Form
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How to fill out the Cobra Enrollment Form online
This guide provides clear instructions on how to complete the Cobra Enrollment Form online. Designed to assist users with varying levels of experience, this guide will help you navigate each section of the form efficiently.
Follow the steps to complete the Cobra Enrollment Form online.
- Press the ‘Get Form’ button to access the Cobra Enrollment Form and open it in the designated editor.
- Fill in the date at the top of the form, ensuring that it reflects the date when you are completing the form.
- In the section labeled 'The Following Questions Pertain to the Employee', enter your full name (Last, First, MI) and your Social Security Number.
- Indicate the relationship of the eligible participant to the employee and their address, including street address, city, state, zip code, and telephone number.
- Select the gender of the eligible participant by checking the appropriate box for Male or Female.
- If applicable, list any dependents that are eligible for continuation coverage along with their names, dates of birth, Social Security Numbers, and relationships to the employee.
- Indicate the group numbers for the medical and dental coverage as 89550 and 89551 respectively.
- Once you have finished filling out the form completely, ensure to save your changes, download, print, or share the form as required.
Start completing your Cobra Enrollment Form online today.
As mentioned, COBRA stands for the Consolidated Omnibus Budget Reconciliation Act. This law ensures that employees have the option to extend their health insurance after certain life events, such as job separation. To take advantage of this option, it's important to fill out the Cobra Enrollment Form accurately and promptly.
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