We use cookies to improve security, personalize the user experience, enhance our marketing activities (including cooperating with our marketing partners) and for other business use.
Click "here" to read our Cookie Policy. By clicking "Accept" you agree to the use of cookies. Read less
Read more
Accept
Loading
Form preview
  • US Legal Forms
  • Form Library
  • More Forms
  • More Uncategorized Forms
  • Cobra Continuation Form

Get Cobra Continuation Form

Apply for COBRA Continuation coverage, please complete all sections of this form and return it to your employer before the election period expires. SECTION 1 QUALIFYING INDIVIDUAL INFORMATION LAST NAME FIRST M.I. GROUP NO. SOCIAL SECURITY NO. ADDRESS (STREET, CITY, STATE, ZIP CODE) MEMBER ID NO. DAYTIME PHONE DATE OF BIRTH SEX SECTION 2 MALE FEMALE SINGLE MARRIED DIVORCED SEPARATED WIDOWED QUALIFYING EVENT INFORMATION MARITAL STATUS I am eligible for c.

How it works

  1. Open form

    Open form follow the instructions

  2. Easily sign form

    Easily sign the form with your finger

  3. Share form

    Send filled & signed form or save

How to fill out the Cobra Continuation Form online

The Cobra continuation form is designed for individuals wishing to apply for continued health coverage after qualifying events. This guide provides step-by-step instructions on how to accurately complete the form online, ensuring you provide all necessary information for your application.

Follow the steps to complete the Cobra continuation form online.

  1. Click 'Get Form' button to obtain the form and open it in the editor.
  2. In section 1, provide your qualifying individual information, including your last name, first name, middle initial, group number, social security number, address, member ID number, daytime phone number, date of birth, and sex.
  3. In section 2, indicate your marital status and select the qualifying event that applies to you, such as termination of employment or legal separation. Provide any relevant dates as prompted.
  4. If applicable, answer whether anyone applying for continuation is covered by another group insurance. If yes, provide the name of the insured and the insurance carrier.
  5. In section 3, review the continuation premium rates for different coverage options. Ensure you understand the rates for employee-only and family coverage.
  6. In section 4, list all dependent family members who will continue coverage. Include their last name, first name, middle initial, date of birth, sex, and relationship to you.
  7. Provide your signature in the designated area confirming that the information you provided is accurate. Enter the date of signing as well.
  8. Once all sections are completed, review the form for accuracy. You can then save changes, download, print, or share the form with your employer.

Take action now and complete your Cobra continuation form online to ensure your health coverage is maintained.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Get form

Related content

Notice to UC of a COBRA Qualifying Event - UCnet
You must also submit a Retiree Continuation, Enrollment or Change form (UBEN. 100) in...
Learn more
bakery and confectinery union and industry...
group health plan including continuation coverage under COBRA. If you do ... An enrollment...
Learn more

Related links form

OH Application For Rental Agreement Lodge/Barn/Picnic Shelters - City Of Stow 2022 OH Rental Registration Application - Boardman Township 2020 OH Land Bank Side Lot Program Request Form - Trumbull County 2019 MI Short Term Rental Registration Form - Spring Lake Township 2017

Questions & Answers

Get answers to your most pressing questions about US Legal Forms API.

Contact support

To apply for COBRA continuation coverage, you must complete the COBRA continuation form provided by your employer. After a qualifying event, you typically have 60 days to submit the form. Ensure you send it to the designated person or address specified in your COBRA notice, as this step is crucial for maintaining your health insurance coverage during the continuation period.

You can obtain COBRA paperwork from your employer or the benefits administrator at your workplace. Many employers also provide access to COBRA forms through their HR portals or websites. Additionally, if you need assistance, platforms like uslegalforms offer a variety of resources to help you find and complete your COBRA continuation form efficiently.

The employer or their benefits administrator typically sends COBRA forms. They are responsible for notifying eligible employees about their rights to continue coverage under COBRA. This notification usually happens after a qualifying event, such as termination or reduced hours. You should receive your COBRA continuation form promptly to ensure you can make informed decisions about your health coverage.

14-Day Notice Period The HR office must provide the COBRA Election Notice and Election Form to qualified beneficiaries within 14 days from the date of the qualifying event or loss of coverage, or when the HR office is notified, whichever comes first.

COBRA continuation coverage lets people who qualify keep their health insurance after their job ends, so it's not surprising that people who receive a COBRA notice might think they're job will soon be terminated. Getting a COBRA notice doesn't necessarily mean you'll be fired or laid off soon, though.

When Federal COBRA ends, eligible employees can buy 18 months additional health coverage under Cal-COBRA. All qualified beneficiaries are generally eligible for continuation coverage for 36 months after the date the qualified beneficiary's benefits would otherwise have terminated.

Q8: How long do I have to elect COBRA coverage? If you are entitled to elect COBRA coverage, you must be given an election period of at least 60 days (starting on the later of the date you are furnished the election notice or the date you would lose coverage) to choose whether or not to elect continuation coverage.

Qualifying Event: At the end of your employment or because of reduction of hours (not maintain full-time status) you will receive this letter. It is VERY important that you review this letter and make your decision if you will need to continue your coverage through COBRA.

COBRA Qualifying Event Notice The employer must notify the plan if the qualifying event is: Termination or reduction in hours of employment of the covered employee, • Death of the covered employee, • Covered employee becoming entitled to Medicare, or • Employer bankruptcy.

This notice has important information about your right to continue your health care coverage in the [enter name of group health plan] (the Plan), as well as other health coverage options that may be available to you, including coverage through the Health Insurance Marketplace at .HealthCare.gov or call 1-800-318- ...

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
Get form
If you believe that this page should be taken down, please follow our DMCA take down processhere.

Industry-leading security and compliance

US Legal Forms protects your data by complying with industry-specific security standards.
  • In businnes since 1997
    25+ years providing professional legal documents.
  • Accredited business
    Guarantees that a business meets BBB accreditation standards in the US and Canada.
  • Secured by Braintree
    Validated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.
Get Cobra Continuation Form
Get form
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232