Get (vsp) Cobra Form - The California State University - Calstate

This guide provides clear instructions on how to complete the (VSP) COBRA Form for The California State University - Calstate. Whether you are the COBRA applicant or an eligible family member, this step-by-step guide will help you navigate the form with confidence.

Follow the steps to successfully fill out the (VSP) COBRA Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Fill in the group name as 'California State University #12292796' and specify the date of the qualifying event, along with the date when COBRA coverage begins.
3. Indicate the qualifying event by checking the appropriate box from the list provided, such as reduction of hours or legal separation.
4. Select the eligibility period for coverage from the options available: 18 months, 29 months, or 36 months.
5. Complete the COBRA applicant information section. Provide your full name, social security number, birth date, social security number of the employee, relationship to the applicant, and mailing address.
6. Fill in the current/former employee information with the employee's name.
7. List all eligible family members by providing their names, social security numbers, birth dates, and relationships to the employee. If there are more dependents, attach a separate listing.
8. Acknowledge the monthly contribution amount of $7.65 and understand that rates may change based on the group’s contract.
9. Review the payment requirements carefully and note that all payments must be made directly to VSP. Familiarize yourself with the payment schedule and grace period.
10. Complete the notification agreement and provide your signature, along with the date. If applicable, a parent or legal guardian must sign on behalf of any minor dependents.
11. Provide a daytime telephone number where you can be reached.
12. To finalize, return the completed form to the address specified: VSP/COBRA Administrator, PO Box 997100, Sacramento, CA 95899-7100.

Take action now by completing and submitting your (VSP) COBRA Form online for continued vision coverage.