Get Coben Cash Enrollment Form - Santa Cruz County Fire

Filling out the COBEN Cash Enrollment Form is an essential step for individuals seeking to enroll in the Consolidated Benefits program offered by Santa Cruz County Fire. This guide provides a clear, step-by-step approach to successfully completing the form online, ensuring you understand each section and can provide the necessary information.

Follow the steps to complete the COBEN Cash Enrollment Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. In the enrollment section, select the appropriate box to indicate your type of enrollment: Open Enrollment, Newly Eligible Enrollment, Change in Status Event, or Cancellation.
3. Enter your Social Security number in the designated field.
4. Type your name, including your first name, middle initial, and last name. Ensure this is clear and accurate.
5. In the COBEN elections section, if applicable, follow the instructions to enter the monthly COBEN cash amount for either Health Only or Health and Dental.
6. Complete the statement regarding other health or dental coverage by certifying whether you are covered by another plan and providing the necessary details.
7. Read and understand the terms stating that your COBEN cash election will continue until you make changes or cancellations, noting any special conditions if you are a permanent intermittent employee.
8. Sign and date the form to agree to the terms and conditions outlined.
9. If required, the agency will complete the employee identification and certification parts of the form.
10. Once you have reviewed all the information, you can now save changes, download, print, or share the completed form as needed.

Complete your COBEN Cash Enrollment Form online today to ensure your benefit options are properly set.