Get Hc 0806 1012 Form 2019

Filling out the Hc 0806 1012 Form 2019 online is an important step for individuals who wish to continue their health benefits coverage under the federal COBRA provisions. This guide will provide you with a clear, step-by-step approach to completing the form accurately and efficiently.

Follow the steps to complete the Hc 0806 1012 Form 2019 online.

1. Click the ‘Get Form’ button to access the Hc 0806 1012 Form 2019 and open it in your online editor.
2. In the first section marked 'To the Family of', enter the name of the individual receiving the notice.
3. Fill in the 'Notice Date' and 'Employer Name' fields with the appropriate information.
4. Complete the 'Emp ID #' section as required, and select the employee type: either 10 month or 12 month.
5. Provide the necessary Social Security Number (SS#) in the designated field.
6. Indicate the reason for the loss of coverage by checking one of the options provided under 'COBRA EVENT'.
7. Fill in the 'DATE OF COBRA EVENT' and 'CONTINUATION TERM' fields to reflect the date and duration of your COBRA eligibility.
8. Complete the 'LAST DATE OF COVERAGE' for medical, dental, Rx, and vision if applicable.
9. Include your employer's contact information, including the name and telephone number.
10. The certifying officer must sign the form in the provided area after it is completed. Make sure to date this section.
11. Proceed to the Health Benefits Program COBRA Application section, beginning with Applicant Information, and fill it in completely.
12. Follow the same method for providing information in the 'CHANGE INFORMATION' section, if applicable.
13. Select the medical coverage and level of coverage options as applicable.
14. List all eligible dependents in the designated section, ensuring required proof documents are attached.
15. In the final sections, check the appropriate boxes for disability extensions if necessary, and provide your name and signature at the bottom.
16. After completing the form, review all entries for accuracy. Save changes, and proceed to download, print, or share the completed form as needed.

Ensure your health coverage continues smoothly by completing your documents online today.