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  • Cobra Election Form Aef-cobra2 11/05

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CENTRAL RESERVE LIFE INSURANCE COMPANY 17800 Royalton Road ? Cleveland, OH 44136-5197 ? 440-572-2400 www.centralreserve.com COBRA ELECTION FORM DIRECTIONS: Employer and employees/dependents, please.

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Massachusets Mini-COBRA Law The 1996 Massachusetts Mini-COBRA Law allows all employees to continue their group health insurance coverage for a limited time if they lose it due to a reduction in hours or termination of employment.

What is COBRA? COBRA stands for Consolidated Omnibus Budget Reconciliation Act of 1985. It allows you and/or your dependents to continue the health and optional insurance coverage (dental and vision) you have through the Texas Employees Group Benefits Program (GBP) for a specified period after you leave employment.

COBRA requires that continuation coverage extend from the date of the qualifying event for a limited period of 18 or 36 months. The length of time for which continuation coverage must be made available (the “maximum period” of continuation coverage) depends on the type of qualifying event.

Form 1095-C, Part II, line 15 enter COBRA premium for the lowest-cost self-only coverage providing minimum value offered. Form 1095-C, Part II, line 16 enter Code 2C. If self-insured, complete Form 1095-C, Part III for all enrolled individuals and in column (e) check applicable months that COBRA coverage was elected.

The three ways to pay COBRA premiums are through ACH (linked to your bank account), credit/debit card or check. We recommend paying by ACH.

Employers should send notices by first-class mail, obtain a certificate of mailing from the post office, and keep a log of letters sent. Certified mailing should be avoided, as a returned receipt with no delivery acceptance signature proves the participant did not receive the required notice.

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.

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.

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© Copyright 1997-2025
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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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
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 workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
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