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  • Cobra Employee Application - Superagent

Get Cobra Employee Application - Superagent

COBRA Continuation of Coverage Application Blue Shield of California and Blue Shield of California Life & Health Insurance Company Employee information Last name First name Social Security number.

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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.

  1. Press the ‘Get Form’ button to access the Cobra Employee Application and open it in the designated editor.
  2. 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.
  3. Indicate the COBRA effective date and select the qualifying event from the provided options. Check the box that corresponds to your situation.
  4. 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.
  5. If applicable, indicate the name of your Personal Physician and the IPA/Medical Group associated with your HMO/POS plan.
  6. Select the existing coverage you wish to continue by checking the relevant boxes for medical, dental, and vision plans.
  7. 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.
  8. After completing the application form, check all the information for accuracy and clarity.
  9. 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.

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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.

You can continue your coverage via COBRA even if you are eligible for a new employer's plan. But, if you waive your new employer's coverage when it's offered to you, you will not be able to enroll in your new employer's plan until the next open enrollment or your next qualifying event.

1. You never received your COBRA enrollment packet. Contact your former employer or your health plan administrator. Perhaps one or the other didn't have your current mailing address on record or there was some other paperwork-processing issue.

The following are qualifying events: the death of the covered employee; a covered employee's termination of employment or reduction of the hours of employment; the covered employee becoming entitled to Medicare; divorce or legal separation from the covered employee; or a dependent child ceasing to be a dependent under ...

If a covered participant or beneficiary requests in writing a copy of these or any other plan documents, the plan administrator must provide them within 30 days. Group health plans must give each employee and spouse a general notice describing COBRA rights within the first 90 days of coverage.

Multiple Qualifying Events The maximum coverage period may be extended to 36 months if a second qualifying event or multiple qualifying events occur within the initial 18 months of COBRA coverage from the first qualifying event. The coverage period runs from the start of the original 18-month coverage period.

Up to 36 months of coverage, when there is a second qualifying event during continuation coverage (the death of the covered employee; the divorce or separation of the employee and spouse; the covered employee becoming entitled to Medicare or loss of dependent-child status under the plan), where the 36 months is ...

Your business has 90 days to provide the employee with a COBRA General Notice, which basically describes the employee's rights and obligations under COBRA. When a qualifying event occurs. Your business must notify the employee of their COBRA rights within 14 days of the qualifying event with an election notice.

The COBRA term can be extended if you become disabled within the first 60 days of COBRA continuation coverage. ... If you qualify, then you and your family may extend your COBRA coverage for an additional 11 months, but you may be required to pay up to 150% of the premium cost for those additional 11 months.

When the qualifying event is the end of employment or reduction of the employee's hours, and the employee became entitled to Medicare less than 18 months before the qualifying event, COBRA coverage for the employee's spouse and dependents can last until 36 months after the date the employee becomes entitled to Medicare ...

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© 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