Get Calpers Cobra Election Form For Actives

This guide provides clear, step-by-step instructions for completing the CalPERS COBRA Election Form for Actives. Whether you are navigating this form for the first time or need clarification, this resource is here to support you.

Follow the steps to complete the CalPERS COBRA Election Form for Actives.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Part A, indicate the type of action: select 'NEW' if this is a new enrollment or 'CHANGE' if you are adding or deleting family members. Specify the qualifying event and original event date in the designated fields.
3. For the COBRA enrollment period, enter the start and end dates based on your qualifying event. Refer to examples provided in the form for guidance.
4. In Part B, complete the enrollee information. Provide the social security number, name, address, city, state, ZIP code, daytime phone number, and birthdate.
5. If the enrollee is a dependent, ensure the subscriber's (employee/retiree) information is filled in as well.
6. In Part C, identify the health plan carrier by providing their name, address, and phone number as required. The COBRA enrollee should continue coverage as per previous enrollment.
7. In Part D, list all family members being enrolled, including the enrollee. Utilize the Action Code to indicate who is being added ('A') or deleted ('D').
8. If applicable, complete Part E by providing information about any prior health plan and necessary codes.
9. Part F requires the enrollee's signature and the date signed, confirming they agree to pay the premiums and understand the terms.
10. Part G is for agency information and must be completed by the health benefits officer. Ensure this section is filled out correctly and submitted along with your form.
11. Finally, save changes, download, print, or share the completed form as necessary.

Ensure to complete your documents online to maintain the benefits you deserve.