Get Wisconsin State Continuation Sample Form

Filling out the Wisconsin State Continuation Sample Form is essential for individuals looking to continue their medical and dental benefits. This guide offers a step-by-step approach to accurately completing the form online, ensuring you understand each section for a successful submission.

Follow the steps to complete your form accurately

1. Press the ‘Get Form’ button to retrieve the Wisconsin State Continuation Sample Form and open it for editing.
2. Begin with the section titled 'THIS SECTION MUST BE COMPLETED'. Fill in your Employee Member Number, Health Group Number, Dental Group Number, and Vision Group Number, ensuring all information is accurate.
3. Next, under the 'COBRA or State Continuation of Coverage Application' section, acknowledge your eligibility for continuation of medical and dental benefits. Contact your employer if unsure about your eligibility.
4. Complete the 'TO BE COMPLETED BY EMPLOYER ONLY' section. Employers should fill in details such as Employee Name, Employer Name, Date of Hire, Last Day Worked, and Last Day of Group Coverage.
5. Identify whether COBRA or State Continuation of Coverage applies based on the number of employees at your workplace. Note the payment instructions clearly, including due dates and monthly premiums for medical, vision, and dental coverage.
6. In the 'TO BE COMPLETED BY EMPLOYEE' section, specify the Date of Qualifying Event and check the relevant box for the event affecting you or your dependent.
7. List the individuals to be covered under the continuation. Include their name, relationship, gender, birthdate, and primary care provider information as necessary.
8. Fill in your mailing address, social security number, and phone number. Review the acknowledgment statement and ensure you have read both sides of the application before proceeding.
9. Finally, sign and date the form to certify your agreement to the matters covered. Save your changes and prepare to download or print the completed form for submission.

Complete your documents online to ensure smooth processing of your benefits.