Get Model Continuation Coverage Election Notice For Pennsylvania Mini Bb - Mbastorage

This guide provides clear and supportive instructions on how to fill out the Model Continuation Coverage Election Notice for Pennsylvania Mini COBRA online. Understanding this form is essential for ensuring continued health coverage.

Follow the steps to complete the election notice.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the date of the notice at the top of the form to document when the notice is being issued.
3. Identify the qualified beneficiaries by entering their names or relevant statuses in the designated field.
4. Review the sections that outline the reasons your coverage may end; check the appropriate box beside your situation (e.g., end of employment, divorce).
5. Indicate the qualified beneficiaries entitled to elect continuation coverage by checking the appropriate boxes next to their names.
6. Fill in the coverage start date and the duration of the coverage as applicable on the form.
7. Enter the cost of continuation coverage for each qualified beneficiary in the specified space.
8. Complete the Continuation Coverage Election Form by providing the necessary details, including name, date of birth, relationship to the employee, and social security number or other identifier.
9. Sign and date the form; ensure that the printed name and relationship to the beneficiaries are correctly filled out.
10. Fill in the address and telephone number in the designated areas to provide contact information.
11. Review all entered information for accuracy before submission.
12. Once completed, return the Election Form via mail or the specified submission method, making sure it is postmarked by the due date.
13. After submission, keep a copy of the completed form and document any communications for your records.

Start completing your documents online today to secure your health coverage.