Get Ceridian Cobra Continuation Services

Filling out the Ceridian COBRA Continuation Services form online is a crucial step for individuals seeking to maintain health coverage after a qualifying event. This guide will walk you through each section of the form, ensuring you understand the requirements and complete it accurately.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the Ceridian COBRA Continuation Services form and open it in your document editor.
2. Review the form thoroughly. Begin by checking the appropriate box for 'Original Notice' or 'Revision' at the top of the form, ensuring that it reflects your situation correctly.
3. Fill out your company information in section 1a, including the name of the company, division, and unit codes as required.
4. Provide the Ceridian Account Number and select whether the qualifying event applies to the employee or dependent in sections 2 and 3.
5. Enter the social security number of the qualified beneficiary in section 4, ensuring the information is correct and clearly printed.
6. In section 15, indicate the specific COBRA qualifying event that resulted in coverage loss by checking the appropriate box. Reference the codes if you need clarification.
7. Fill in the address details of the qualified beneficiary in sections 5a to 5e, including their name, street address, city, state, and zip code.
8. Provide contact information in section 6. Make sure to include a home phone number with the area code.
9. Complete sections regarding subsidies in questions 18 and 19, if applicable, and confirm the applicable start and end dates for the subsidy.
10. Review all entries for accuracy and clarity. Once completed, you can save the changes, download, or print the form directly from your editor, and ensure to submit it to the Ceridian COBRA Services Center.

Take action now and complete your Ceridian COBRA Continuation Services form online.