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Get Cobra Employee Application - Superagent
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How to fill out the Cobra Employee Application - SuperAgent online
The Cobra Employee Application - SuperAgent is designed to help users apply for continued health coverage under COBRA provisions. This guide provides a step-by-step approach to filling out the application to ensure you provide all necessary information accurately.
Follow the steps to complete your Cobra Employee Application online.
- Press the ‘Get Form’ button to access the Cobra Employee Application and open it in the designated editor.
- Begin filling out the 'Employee Information' section. Provide your last name, first name, middle initial (MI), Social Security number, Blue Shield ID number, and the date of the qualifying event.
- Indicate the COBRA effective date and select the qualifying event from the provided options. Check the box that corresponds to your situation.
- Complete the 'Covered Member Information' section by providing the Social Security number, Blue Shield ID number, last name, first name, MI, address, city, state, ZIP code, phone number, date of birth, sex, and marital status.
- If applicable, indicate the name of your Personal Physician and the IPA/Medical Group associated with your HMO/POS plan.
- Select the existing coverage you wish to continue by checking the relevant boxes for medical, dental, and vision plans.
- List all dependents eligible for coverage. Ensure only dependents previously enrolled on the group plan are included, and provide their relation, last name, date of birth, and Social Security number.
- After completing the application form, check all the information for accuracy and clarity.
- Finalize the process by signing the form. You can then save changes, download, print, or share the completed document as necessary.
Complete your Cobra Employee Application online today to secure your health coverage.
You'll have 60 days to enroll in COBRA or another health plan once your benefits end. But keep in mind that delaying enrollment won't save you money. COBRA is always retroactive to the day after your previous coverage ends, and you'll need to pay your premiums for that period too.
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